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The Situation Analysis Approach to Assessing Fatnily Planning and Reproductive Health Services

A Handbook

Robert Miller • Andrew Fisher • Kate Miller Lewis Ndhlovu • Baker Ndugga Maggwa • Ian Askew Diouratie Sanogo • Placide Tapsoba

4J Population Council

, Mrica Operations Research and II T. Technical Assistance Project fJ Library of Congress Cataloging-in-Publication Data

The situation analysis approach to assessing family planning and reproductive health services: a handbook / Robert Miller ... let al.]. p. cm. Includes bibliographical references. ISBN 0-87834-090-4 (paperback: alk. paper) 1. Birth control--Research. 2. Birth control--Data processing. 3. Maternal health services--Evaluation. 4. Evaluation research (Social action programs) I. Miller, Robert, 1942- II. Population Council. HQ763.5.S57 1997 97-5428 363.9'6' 072--DC21 CIP

The Population Council seeks to improve the wellbeing and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance be­ tween people and resources. The Council, a nonprofit, nongovernmental research organization estab­ lished in 1952, has a multinational board of trustees; its New York headquarters supports a global network of regional and country offices.

Population Council One Dag Hammarskjold Plaza New York, New York 10017 USA tel: (212) 339-0500 fax: (212) 755-6052 email: [email protected] http://www.popcouncil.org

The authors are staff members of the Population Council. Robert Miller is Senior Program Associate, New York; Andrew Fisher is Program Director, Family Planning, and Senior Program Associate, New York; Kate Miller is Staff Program Associate, New York; Lewis Ndhlovu is Program Associate, Nairobi; Baker Ndugga Maggwa is Program Associate, Nairobi; Ian Askew is Project Director and Senior Program Associate, Nairobi; Diouratie Sanogo is Deputy Director for West Africa and Program Associate, Dakar; Placide Tapsoba is Program Associate, Dakar.

This publication was supported by the Population Council's Africa Operations Research and Technical Assistance Project II, Project No. 936-3030 and the Population Council's Expanding Contraceptive Choice Program. The Africa OR!TA Project II is funded by the U.S. Agency for International Develop­ ment (USAID), Office of Population, Contract No. CCP-3030-C-00-3008-00, Strategies for Improving Family Planning Service Delivery. The Expanding Contraceptive Choice Program is also funded by USAID, Cooperative Agreement No. CCP-3050-A-00-4013.

© 1997 by The Population Council, Inc.

Any part of this document may be reproduced without permission of the authors so long as it is not sold for profit. We would appreciate receiving comments and suggestions from readers, and reports from those who carry out Situation Analysis studies. Contents

Abbreviations iv Foreword v Foreword vi Preface and acknowledgments vii How to use this handbook ix

Chapter 1 Chapter 3 The Situation Analysis study Instruments and methodology question-by-question guides Objectives of a Situation Analysis study 3 Inventory 29 Basic elements 4 Inventory: Study design 6 question-by-question guide 43 Data collection instruments 7 Observation guide 50 Study implementation 8 Observation: question-by-question guide 59 Programmatic uses of Situation Analysis studies 9 Family planning client exit interview 66 Impact studies and Situation Analysis 10 Family planning client exit interview: Operations research and question-by-question guide 98 Situation Analysis 11 Staff interview 110 The diffusion of Situation Analysis 12 Methodological issues 12 Staff interview: question-by-question guide 125 Conclusions 14 MCH client exit interview 131 References 14 MCH client exit interview: Chapter 2 question-by-question guide 149 Conducting the study Chapter 4 Ethical issues in the conduct of Data analysis and reporting Situation Analysis studies 17 Data entry and cleaning 157 Establishing objectives and reviewing questionnaires 20 Analysis plan 160 The training agenda for Notes to analysis plan 184 the research team...... 20 Sample indicator lists 187 Role of the Team Leader/Supervisor 21 Sample graphs 192 The research team and a typical day 23 Tips for conducting a good interview 23 Tips for conducting a good observation 24 After data collection 25 Abbreviations

AIBEF Association Ivoirienne Pour Ie LAM Lactational Amenorrhea Method Bien-Etre Familial LMP Last Menstrual Period AIDS Acquired Immunodeficiency MCH Maternal and Child Health Syndrome MIS Management Information System ANC Antenatal Care ML/LA Mini-Laparotomy / Local AV Audiovisual Anaesthetic BCG Calmette-Guerin bacillus MOH Ministry of Health (vaccine) NFP Natural Family Planning BKKBN National Family Planning Coordinating Board (Indonesia) NGO Non-Governmental Organization BP Blood Pressure OR Operations Research CBD Community-Based Distribution PID Pelvic Inflammatory Disease CIOMS Council for International POP Progestin-Only Pill Organizations of the Medical PRICOR Primary Health Care Operating Sciences Research COC Combined Oral Contraceptive QA Quality Assurance DHS Demographic and Health RH Reproductive Health Surveys RTI Reproductive Tract Infection DHT District Health Teams SA Situation Analysis DPT Diphtheria, Pertussis, and SAM Service Availability Module Tetanus Toxoid (vaccine) SDP Service Delivery Point EPI Expanded Programme of Immunizations SPSS Statistical Package for the Social Sciences FP Family Planning SID Sexually Transmitted Disease FPA Family Planning Association TA Technical Assistance FWE Family Welfare Educator TL Tubal Ligation HIV Human Immunodeficiency Virus USAID United States Agency for IEC Information, Education, and International Development Communication WFS World Fertility Surveys IUD Intra-Uterine Device ZNFPC Zimbabwe National Family KAP Knowledge, Attitude, and Planning Council Practice

'V Abbreviations ·1 Foreword

The mission of family planning managers, have lacked a picture of what clients re­ indeed of professionals in the family plan­ ceive in the way of care. ning field, is to assure that clients receive This is where the tool called Situation prompt, safe, and respectful care. Family Analysis comes in. It provides a much­ planning managers who take this mission needed link between the manager and the seriously have the responsibility of orches­ client he or she is trying to serve. The data trating resources, staff, and service structures marshaled for the Situation Analysis offers a to meet the needs of many thousands and, representative picture of how subsystems in some cases, many millions of individuals. are working and provides a way to "see" the But in the past, there have been few tools to client's experience. Situation Analyses assist guide managers concerned about the quality the manager in achieving the broadest man­ of care clients receive. Whereas in recent agement goal-that of efficient adminis­ years there has been good national-level in­ tration of a vital health care service- formation about the quality of inputs such as while keeping firmly in the viewfinder the the steadiness of contraceptive supplies, and ultimategoal-providing good care for societal level outcomes such as contracep­ those who seek it. tive prevalence, managers in general have not had information about what the family Judith Bruce planning staff are actually doing, the degree Program Director to which they are prepared to respond to Gender, Family, and Development clients' actual needs, and most vitally they Population Council

Foreword • v Foreword

Good family planning service delivery em­ One of the most valuable attributes of phasizing both access and quality is key to Situation Analysis is the simplicity of the the related twin goals of both satisfying indi­ results. For example, consider a Situation vidual needs and achieving programmatic Analysis that fmds that half of all service success. As a consumer of data and scientific delivery sites have had a stock-out of inject­ literature on family planning, I have found able contraceptives in the last six months or Situation Analysis a gold mine of useful in­ that side effects of methods are discussed with formation. It is the first systematic data col­ new clients only half the time. Such fmdings lection tool which credibly documents what are clear and direct for managers and for oth­ goes on inside the formidable "black box" of ers. They are also very common. Indeed one service delivery. In my view, it ranks with of the major lessons from Situation Analysis the Demographic and Health Surveys as a is the large gap between the ideal and real­ seminal methodology for our field. ity. On the one hand such findings can be At the same time, it is important to disappointing, but they also offer hope. bear in mind some of the limitations of They represent situations that can (at least in Situation Analysis. It is a snapshot of principle) be easily improved. In my view the reality of service delivery, and findings the most important lesson from the collec­ are undoubtedly influenced by the mere tive findings from Situation Analysis is the presence of the observers. Likewise, the huge amount of improvement in access and valuable information Situation Analysis pro­ quality that is potentially within our grasp. vides has tended to come with a consider­ Well-executed tools such as Situation Analysis able price tag, and results are best can help make such improvements reality. interpreted in light of the service delivery context from which they come. We need to James D. Shelton continue to improve the Situation Analysis Senior Medical Scientist methodology and develop and improve Office of Population other tools to evaluate and enhance service United States Agency for delivery access and quality. International Development

Foreword • vi Preface and acknowledgments

Situation Analysis (SA) studies began in Africa. terns prevalent. As the Cairo paradigm encour­ The first was conducted in Kenya, in 1989, aged attention to much broader issues in re­ with the collaboration of the Division of Fam­ productive health-especially HIV/ AIDS and ily Health, Ministry of Health. Since that time, sexually transmitted diseases-African re­ SA studies have been implemented in three searchers were particularly well-placed and dozen countries around the world with the co­ supported in their efforts to broaden their cov­ operation and support of national family plan­ erage of reproductive health issues. The cur­ ning program managers, and the hard work rent SA instruments reflect the broader, and commitment of many hundreds of re­ integrated, reproductive health approach, al­ searchers, interviewers, and supervisors. We beit viewed from the family planning perspec­ are deeply indebted to all who have been in­ tive. Second, because many African countries volved with conducting these studies for their lack a functioning Management Information enthusiasm, hard work, and willingness to en­ System (MIS), the SA instruments collect con­ dure the hardships of field research. We are siderable information on commodities, stock also deeply indebted to the thousands of fam­ positions, client utilization, etc., information ily planning and reproductive health staff who that in Asian and Latin American countries of­ welcomed our field research tearns at their fa­ ten comes directly from a functioning MIS. cilities, often found places for them to sleep, Despite having been designed to ad­ opened their cupboards for inspection, allowed dress African programs, the SA methodology their clients to be interviewed and observed, and has benefitted from innovative contributions patiently answered our numerous questions. from colleagues in other regions. For ex­ Although the development of the meth­ ample, the first linking of Situation Analysis odology was greatly assisted by colleagues SDPs with the DHS clusters in which they working on operations research projects in were located was done in Peru under the di­ many different regions, the original instru­ rection ofJames Foreit. Other innovations ments evolved in Africa and this particular it­ stemming from the Peru SA experience in­ eration ofthem may still carry something of an clude a scheme for studying logistics chains African perspective. For example, first, African and the first pharmacy module. Huntington countries have developed integrated programs et a1.1 carried out a study of SA observer re- of matemal-child health and family planning (MCH/F'P) that operate within ministries of 1 D. Huntington, K. Miller, and B. Mensch, 1996. health. Many Asian and Latin American coun­ "The reliability of the situation analysis observation tries have free-standing family planning sys- guide." Studies in Family Planning 27,5: 277-282.

Preface and acknowledgments • vii /'\ f \..? liability in Turkey and have utilized the meth­ impact of service quality on the behavior odology to focus on sterilization services and outcomes of clients; and how the data and abortion services. It would be difficult to collected throughout the world can be made fully represent all of the exciting adjustments easily available to a wider group of re­ to the methodology and creative innovations searchers and managers. that are under way as researchers in other re­ Throughout the process of SA develop­ gions adapt the material to emphasize their ment and implementation we received con­ particular national and regional concerns. siderable support (financial as well as This volume represents our attempt to technical) from USAID Washington and bring out an up-to-date version of proce­ many USAID Missions. We are greatly in­ dures and materials as they have evolved debted to USAID for this support and for over the past eight years. We have no doubt their encouragement. The high level of en­ that many additional issues need further de­ couragement, frequent utilization of study bate, testing, and change; and that the in­ findings, technical support, and numerous struments as well as some of the procedures suggestions for strengthening the methodol­ may need to be adjusted to new applications ogy are also gratefully acknowledged. We and specific settings. Important unsolved also benefited richly from the comments, questions include: whether the number of suggestions, willingness to debate, and cre­ variables included in the SA studies should ative research of numerous staff of the be reduced for manageability, or increased Population Council-both in New York and to cover an ever-expanding number of re­ in regional offices around the world. Their search issues; whether and under what cir­ numbers are so great that we hesitate to cumstances the SA studies should be provide a list, and fear that any developed integrated with population-based survey might neglect a deserving colleague. Simi­ studies in order to possibly obtain a more larly, our colleagues in USAID's Collaborat­ complete picture of both demand and sup­ ing Agencies have supported this entire ply considerations; how the reproductive effort through assisting in the implementa­ health components of the study (and indeed tion of field studies, encouraging the dis­ entire health systems) can be more ad­ semination and utilization of the study equately and independently appraised findings, and teaching their students and through the application of a similar but ex­ colleagues to use and improve it. panded methodology; whether the instru­ Although the credit for development of ments should be standardized in order to the methodology is shared by many, we promote cross-national comparisons, or con­ take full responsibility for errors and tinually adjusted to meet country concerns shortcomings. and changing management concerns; how SA studies can play a role in researching the The Authors

Preface and acknowledgments • viii How to use this handbook

This book is a tool to help implement Situa­ ing the study in the field. This chapter fo­ tion Analysis (SA) studies. It is not meant to cuses on the training of field workers, and be read cover to cover. Some of the sections will be of particular interest to staff con­ of this handbook may be more useful and cerned with study implementation. This interesting for policymakers and program chapter can be photocopied and distributed planners, other sections for researchers, and to the field interviewers and trainees. It may still other sections for field interviewers. also help program and policy decision-mak­ Each chapter of the handbook is briefly de­ ers to understand the practical steps in study scribed below. implementation.

Chapter 1: The Situation Analysis Chapter 3: Instruments and ques­ study methodology introduces and pro­ tion-by-question guides provides the core vides background to the research methodol­ interview schedules, inventory, and observa­ ogy and a variety of related conceptual tion guide, which can be adjusted by plan­ issues. This chapter, versions of which have ners to suit particular national or regional been published elsewhere, gives an over­ interests. This section also supplies instruc­ view of SA study objectives, research design, tions and background information on each interviewer training, field data collection question, geared toward the data collectors. procedures, data uses, and methodological After the instruments and related question­ issues. This information may be useful for by-question guides are adjusted to local researchers, evaluators, program managers, circumstances, this section should be photo­ policy decisionmakers, donor agencies, and copied and made available to all field staff the many technical assistance personnel involved with the study. It will serve as working in agencies around the world. The the main aid during training of the field chapter is intended to help decision-makers researchers and an important reference understand the value and limitations of the document for them. type of data collected, and to assist them in making an informed decision about whether Chapter 4: Data analysis and report­ to carry out such a study. ing provides advice on entering and clean­ ing data, and instructions for producing an Chapter 2: Conducting the study initial SA report for discussion by research­ supplies practicalguidance for implement- ers, program managers, clinic personnel,

How to use this handbook • ix donors, and others. It provides a complete and researchers to agree on the analysis list of primary results that can be computed plans before the study begins. After agree­ from the SA instruments, with reference to ment is reached, this section will be useful the questions that are needed for each re­ for those charged specifically with the analy­ sult. It also includes several sample graphs sis of the data. This chapter assumes at least and sample indicator lists from two coun­ a minimum proficiency with data processing tries. It is important for program managers programs (such as Epi Info or SPSS).

How to use this handbook • x Chapter I

The Situation Analysis study methodology

Family planning programs have evolved use or not to use contraception (their over the last thirty years into complex orga­ knowledge and attitudes) and about their re­ nizational structures requiring detailed infor­ ported current and past use (their practices). mation on the functioning and quality of KAP surveys do not provide information service delivery subsystems such as training, about the potential of the service delivery supervision, logistics, and information, edu­ environment to provide quality of care to cation, and communication (lEC).1 The rapid clients, or about the actual provision of ser­ expansion of these programs has often put vices to clients. In short, they focus on the heavy demands on managers to know how demand for services, not on the supply of these subsystems are functioning, and what services. should be done to improve performance As a guide for program planning and ser­ and extend services. Unfortunately, national vice improvement, KAP surveys may not family planning programs often lack viable have been very helpful. Indeed, it can be ar­ management information systems (MIS) that gued that they have tended to highlight the might be capable of providing some infor­ knowledge, attitudes, andpractices ofclients mation for guiding managerial decisions. As as the source of problems for programs try­ has been well-documented by Keller (1991), ing to achieve demographic goals, rather most MCH/FP programs have extremely than focus on the availability, accessibility, weak MIS and in those programs that do and quality ofprograms as the source of have an MIS, "information is too infrequently problems for clients trying to reach their brought to bear on management decision­ own reproductive health goals. For example, making" (Keller, 1991:19). low levels of knowledge about family plan­ In part because of this, program managers ning and unfavorable attitudes are often at­ and others for many years have relied on tributed to traditional client values and low population-based surveys as a source of in­ education levels, and less frequently to formation to guide program development. The ubiquitous nature of these surveys and their numerous problems have been known 1 This chapter is based on A. Fisher, R. Miller, for some time (Cleland, 1973). Usually these 1. Askew, B. Mensch, A. Jain, and D. Huntington, surveys go under the heading of KAP­ "The Situation Analysis approach to assessing the supply side of family planning programs," Popula­ Knowledge, Attitude, and Practice. Whatever tion Council, September 1994. A shorter and modi­ the name, at best they can only provide in­ fied version will appear in TheJournal ofthe Center formation about the potential of couples to for African Family Studies, forthcoming, 1997.

Situation Analysis study methodology • 1 poorly planned and implemented lEC activi­ for measuring the supply side of family ties, or weak counseling as a result of poor planning programs originated with a request provider training. Similarly, low levels of con­ to the Africa Operations Research Project for traceptive use are often attributed to a lack of assistance in determining the equipment interspousal communication, male resistance needs at service delivery points (SDPs) in to family planning, or religious values, and less Kenya (Miller et al., 1991). Through discus­ frequently to a lack of commodities, formi­ sions, the final research approach adopted dable barriers to access by males as well as fe­ was broadened to include more complete males, or poor quality of services at clinics. information on the availability, functioning, Spearheaded in a large part by operations and quality of services at the SDPs. An im­ research, the focus of much family planning portant catalyst for focusing on supply side research in recent years has shifted some­ information was a general feeling that KAP­ what to examining factors that affect the type surveys simply could not be used to supply of services. A fairly standard opera­ provide guidance for the selection of pro­ tions research methodology (Fisher et al., gram options. For example, despite numer­ 1991) has been used to generate a large ous KAP surveys, at the time of the original number of studies (Ross and Frankenberg, request for a study in Kenya, there was sim­ 1993; Fisher, 1993) that examine the func­ ply no information on the potential or the tioning of programs and the activities or actual ability of service delivery points to "operations" that are under the control of provide services. It was not known if the managers and can be manipulated through SDPs were fully equipped and staffed. It was administrative action to produce program not known if lEC materials were available change. While demand factors are clearly and being used. It was not known if contra­ important determinants of contraceptive use, ceptive commodities in sufficient quantities there is now a general recognition that ef­ were available. Beyond these areas that re­ fective family planning programs also de­ late to the potential of an SDP to provide pend at least as much on the availability of a services, there was only anecdotal informa­ range of commodities for client choice, on tion on the quality of care actually being re­ sound training and supervision for compe­ ceived by clients. tent providers, on understanding clients' These supply side factors that affect the needs for effective provider-client informa­ service delivery environment and quality of tion exchange, on facilitating continuity of care have long been recognized as impor­ contraceptive method use, and on provider tant (Freedman, 1974). Both the World Fertil­ attitudes that affect their relationship with ity Surveys (WFS) and the more recent clients and the provision of services. These Demographic and Health Surveys (DHS) areas are widely viewed as the fundamental have had a community module, called a Ser­ elements of quality of care (Bruce, 1990) vice Availability Module (SAM) by the DHS, and are thought to have a major effect on intended to collect information on the ser­ the ability of couples to meet their repro­ vices and facilities available in a geographic ductive intentions. area. However, experience with community The development and subsequent evolu­ modules has not always been viewed as sat­ tion of the Situation Analysis methodology isfactory (Casterline, 1985). In part, one rea-

Situation Analysis study methodology • 2 son for this has been reliance on knowl­ and facilities to provide quality ser­ edgeable informants as a source of informa­ vices to clients against the current poli­ tion about the facilities and services. cies and program standards; Wilkinson (1991) has pointed out that 3. To describe the actual quality of care knowledgeable informants are not always received by clients; completely knowledgeable. They sometimes 4. To evaluate the impact the provision are unaware of the range of services avail­ of quality services has on client satis­ able at facilities or indeed, even about the faction, contraceptive use dynamics, existence of particular facilities in a geo­ fulfillment of reproductive intentions, graphic area. As discussed below, the Situa­ and ultimately, on fertility (in ex­ tion Analysis approach avoids the use of panded research designs, most often knowledgeable informants and relies iristead using a panel of respondents). on interviews with providers and clients The relationship between the four objec­ coupled with direct observation by trained tives and three levels of measurement-na­ study investigators of facilities and services. tional level, program service delivery point This approach appears to result in more level, and client level-is shown in Figure 1. comprehensive and accurate data (Arends­ As one moves from objective 1 through 4, Kuenning et al., 1996). there is a concomitant increase in the com­ plexity of study design, data collection pro­ Objectives of a Situation cedures, and data analysis. Also, there is an Analysis study increase in the time and cost required for The Situation Analysis approach to research study implementation. For example, the on the supply side of family planning pro­ study implied by objective 1 is primarily de­ grams has four essential objectives: scriptive in nature and is intended to pro­ 1. To describe the potential of current vide information on the extent to which policies and program standards to national-level family planning policies and promote the delivery of quality ser­ SDP-level standards tend to facilitate and vices to clients; promote the delivery of quality services to 2. To describe and compare the current clients or act as barriers to their delivery. readiness of service delivery staff The national policies and SDP-Ievel stan- dards are con­ cerned with a FIGURE 1. Four objectives of Situation Analysis studies variety of issues such as import To describe: Policyl Service Services IImpact standards readiness received . duties on con- III -~~==~~====---====~====--'====='- j National IPolicies traceptives, cost 1: for services, ~ Staff/Facilities/ SDP IStandards who can receive l!! Equipment = contraceptive i Client Quality Client knowledge/ :!E received Behavior methods, the methods that all Adapted from Kumar et al.. 1989. SDPs should

Situation Analysis study methodology • 3 have available, the competencies staff courage clients to switch methods if they ex­ should possess, the information that should perience problems, discuss issues related to be given to clients, etc. (Although not all SA STDs, or ask questions to understand fully studies have included this objective, an SA the reproductive goals of a client. interview schedule for managers does exist The fourth objective, related to impact, and has been used in several sites.) implies a fairly complex study that might use The second objective implies a descrip­ a prospective, longitudinal design to collect tion of the existing situation at service deliv­ data over time in order to test one or more ery points. Typically this "basic" Situation hypotheses concerning the "impact" a par­ Analysis study describes the extent to ticular configuration of services or level of which the current service delivery system is quality has on client satisfaction, contracep­ "ready" to provide quality services. At the tive use, and the ability of couples to meet SDP level, readiness to deliver quality of their own reproductive intentions in a safe care services means that staff are available, and healthful manner. The examination of trained, and competent to give services; impact requires either that a Situation Analy­ commodities and equipment are available, sis study be linked with a KAP-type popula­ functioning, and used; and the facility is ad­ tion-based study; or that two or more basic equate to handle the client load. In other Situation Analysis studies be conducted over words, the conditions for the delivery of time, and a panel of respondents be fol­ quality services exist. lowed from one study to the next (see sec­ The third objective suggests a more ana­ tion below). lytic study which 1) describes the quality of services received by the client, that is to Basic elements say, the interaction between the provider The development of the Situation Analysis and the client, and 2) compares the potential methodology was influenced by the systems readiness of the program to provide quality thinking of PRICOR (Center for Human Ser­ services against the actual receipt by clients vices, 1988), by Frerichs's Rapid Survey of quality services. For example, a clinic that Methodology (Frerichs, 1989a, and Frerichs does not have contraceptive commodities, and Khin Tar Tar, 1989b), and by the quality trained staff, and basic equipment does not of care framework outlined by Bruce and have the potential to provide quality ser­ Jain (Bruce 1990). In developing the meth­ vices. Such a clinic is simply not ready to odology, several assumptions were made: 1) provide family planning services of any It would be valuable to have a picture of kind, let alone quality services. On the how all major family planning subsystems other hand, the presence of commodities, were functioning rather than focus on just trained staff, and basic equipment is not a one or two such as equipment or lEe. 2) guarantee that quality services actually will The performance of various tasks and be received by a client. A provider, even subtasks within a particular subsystem was highly trained, may not want to give services probably highly correlated so that the collec­ to unmarried adolescents, offer clients a full tion of data on a limited set of subsystem in­ range of methods, fully describe each dicators instead of all would probably be method, discuss side effects of methods, en- sufficient in order to determine whether the

Situation Analysis study methodology • 4 subsystem was functioning.2 3) In order to availability module; (5) recording of make inferences about the supply side fac­ clinic facilities, equipment and com­ tors influencing the delivery of services, modities available on the day of the either a representative sample of SOPs or a team visit; and (6) nonparticipant di­ census of all SOPs would have to be visited. rect observation of all family planning 4) Oata collected through actual observa­ client-provider interactions on the day tions of facilities and staff behavior, as well of the research team's visit." as interviews with SOP service providers All Situation Analysis studies have a basic and their clients, would yield richer and core set of procedures and approaches to more valid information than interview re­ the collection of data. These core proce­ sponses from key informants. dures and approaches include: The research approach that evolved from •A representative sample of SOPs, or all the Kenyan study was called a Situation SDPs within a geographic area of inter­ Analysis, defined as: est (country, city, district, province), are A description and evaluation of visited for at least a full day by a team 1) currentfamily planningpolicies and of at least three people, including at service delivery standards; and the least one with clinical training (a physi­ availability andfunctioning offamily cian, nurse, nurse/midwife) and at least planning subsystems at a representative one with a social science background sample or all service deliverypoints and field interview experience. (SDPs) in a geographic area; 2) the •A complete inventory is taken of readiness ofthese subsystems to deliver equipment and supplies. quality ofcare to clients; 3) the actual • Service statistics (if available) are re­ quality ofcare received by clients at these corded for the past 12 months. SDPs; and 4) the impact quality ofcare • All family planning service providers has on thefertility behavior ofclients. are interviewed regarding family Mensch et al. (l994a) noted: planning and other reproductive "Although Situation Analysis borrows health issues. from other methodologies, it is consid­ • Observations are made of the interac­ ered innovative because it integrates a tion between service providers and all number of approaches to family plan­ new and continuing family planning ning program evaluation. These in­ clients on the day of the visit. clude: (1) a systems perspective for • All clients observed are subsequently identifying crucial subsystem compo­ interviewed as they leave the SDP. nents of program operation; (2) visits A selection of MCH clients are also to a large sample of SOPs rather than interviewed. visits to only a few SOPs or reliance on Some SA studies also include interviews expert opinion; (3) a client-oriented fo­ with program managers, observations of cus on quality of care; (4) structured 2 The complete PRICOR Thesaurus was passed interviews with managers, providers, over in favor of a simpler and quicker approach and clients rather than with community using fewer variables deemed more suited to a informants as is the case with the OHS large sample study.

Situation Analysis study methodology • 5 TABLE 1. Sample sizes of selected Situation Analysis studies

Number of Provider-elient Client exit Interviews Executing Country Year SOPs observations interviews with staff agency

Sub-Saharan Africa Botswana 1995 184 406 386 456 Ministry of Health Burkina Faso 1992 53 66 193 93 Ministry of Health Burkina Faso 1995 337 509 509 685 Ministry of Health Cote d'ivoire 1992 13 163 355 51 AIBEF Ghana 1993 399 665 655 783 Ghana Statistical Office Kenya 1989 99 72 72 99 Ministry of Health Kenya 1995 254 1029 997 562 Ministry of Health Nairobi City 1991 46 100 100 46 Nairobi City Commission Nigeria 1992 181 395 390 289 Obafemi Awolowo University Senegal 1994 180 1123 985 361 Ministry of Health Tanzania 1992 348 450 436 537 Ministry of Health Tanzania (Mbeya) 1995 52 111 111 120 Family Health Project Zanzibar 1995 100 145 145 191 Ministry of Health Zimbabwe 1991-92 181 463 463 378 ZNFPC

Asia Indonesia 1994 342 1625 1624 651 BKKBN Pakistan 1993 84 103 203 83 Ministry of Population Welfare Turkey 1994 115 1006 975 232 Ministry of Health

Latin America Ceara, Brazil 1993 40 17 17 47 Sociedade Cearense de Pediatria Guatemala 1993 38 na 331 71 Ministry of Health/FP Unit Peru 1992 2970 599 599 1951 Ministry of Health and National Statistical Institute

non-family planning services, and specialized such as pharmacists, private hospitals, pri­ questionnaires for CBDs and pharmacies. vate physician clinics, and employment (fac­ tory, mining, or large farm) based outlets. In Study design short, any and all sources of family plan­ The units of analysis for a Situation Analysis ning and health services and supplies po­ study are service delivery points. Rather than tentially could be examined in a Situation a single clinic or delivery system, multiple Analysis study. The first decision that must SDPs and types of delivery systems (MOH be made, therefore, is which type of SDP clinics, CBDs, NGO clinics, pharmacies, etc.) should be evaluated. Once this decision representative of the situation in a country has been made, a plan can then be formu­ or region are examined. The SDPs might in­ lated to include the entire universe of clude government and parastatal clinics and SDPs in the study or more likely, to develop CBD outlets, NGOs outlets, commercial units a sampling strategy.

Situation Analysis study methodology • 6 If the objective of the Situation Analysis will not be enough time to examine fully study is to diagnose and describe the avail~ each subsystem. In some cases, it may be ability, functioning, and quality of services in advisable to spend more than a single day at the entire country, sampling of SDPs is al~ each SDP (see discussion of this point be­ most always necessary. Ideally, the sample low). The data collection team should be should be representative of SDPs in terms of present slightly before the SDP is scheduled type (hospital, clinic, CBD, etc.) services to open and should stay until it closes. provided (family planning alone or inte~ The basic minimum data collection instru­ grated with reproductive health), geographic ments are: location (region, urban/rural), and type of • Inventory for Facilities Available and sector (public, NGO, private, etc.). This re~ Services Provided at the Service Deliv­ quires a detailed list of the location of all de~ ery Point livery points as well as some knowledge of • Observation Guide for Interaction the type of SDP in each locality. Assuming a Between Family Planning Clients and list of all SDPs is available, a simple random Service Providers sample can then be drawn, or, more likely, • Exit Interview for Family Planning some form of stratified random sample, with Clients the units drawn proportionate to the num~ • Interview for Staff Providing Family ber in a strata. Usually samples are stratified Planning/Reproductive Health Services according to the classifications mentiqned at the Service Delivery Point above: region, type of SDP, sector, etc. Table • Interview for MCH Clients Attending 1 summarizes the sample sizes used in re~ the Service Delivery Point cent Situation Analysis studies. Because generally only a few family plan­ ning clients are available on the day of the Data collection instruments visit, it is not possible to make an accurate A number of data collection instruments are assessment of quality of care at any given needed in order to obtain information on individual SDP. However, aggregating all cli­ the three primary areas of interest (availabil~ ents across all clinics in the sample can pro­ ity, functioning, and quality). Some of these vide a reasonably valid inference about instruments must be used in all Situation quality of care for the country or region as a Analysis studies, otherwise the minimum set whole. If quality at the individual SDP level of data required to describe subsystem func~ is desired, information on a larger number tioning and quality cannot be obtained. of clients must be obtained. This can be Other instruments are optional but may en­ done by 1) spending more time (possibly as rich the study findings when used. long as a week or more) at each SDP, or In a study of fixed SDPs such as clinics 2) stratifying SDPs by subsystem functioning and hospitals, the basic Situation Analysis in­ or client load, selecting a few SDPs per struments can be utilized. The administration strata, and spending more time collecting of these instruments will take approximately data on clients. four to six hours per SDP depending on the Depending on the service delivery system client load at the SDP. Only one SDP should being studied, additional instruments may be be covered in a single day, otherwise there administered. For example:

Situation Analysis study methodology • 7 • Questionnaire for Program Managers Study implementation and Policymakers The number of research teams and supervi­ • CBD Interview Schedule sors used in a study depends on the number • CBD Client Observation Form and accessibility of SDPs, the objectives se­ • CBD Client Exit Interview lected, and resources available. Usually, each • Pharmacy Interview Questionnaire research team consists of three persons-at In some SDPs, especially in countries with least one with clinical training (a physician, low contraceptive prevalence, it may not be nurse, nurse/midwife) and at least one with possible to find many or even any new and a social science background and field inter­ continuing clients who can be interviewed. view experience. It is recommended that a In such instances, the instrument for MCH single supervisor coordinate no more than clients can help to ascertain the reasons three research teams. for non-use of services by women living Typically, at the beginning of the day, the within easy reach of the SDP. If a family person with clinical training will begin ob­ planning program includes CBD workers serving client and provider interactions. who provide a substantial number of clients Later, this person will also help one of the with contraceptive supplies, then a CBD other team members to complete the inven­ instrument also can be developed and tory of equipment. The social scientist usu­ used. CBD instruments have been used ally will be responsible for client exit in a few countries (for example, Zimbabwe interviews and staff interviews. He/she may and Mali) and are available from the also help with collecting information Population Council. on clinic records, reporting, and service There are many other questionnaire statistics. modules that can be added to the standard The training of the research teams is questionnaires. For example, the Situation probably one of the most important aspects Analysis methodology can be used to of any Situation Analysis study. Unlike KAP­ examine the links (integration) between type surveys, Situation Analysis studies use a reproductive health care services (postpar­ variety of data collection techniques such as tum, antenatal, abortion, STD and HIV) observation and inventory-taking which re­ and family planning services. Also, in quire substantial training. Ten full days of countries where sterilization is important, a training is essential as a minimum. The train­ module that examines this service in ing should include considerable role playing greater detail can be added. In short, the as well as actual field visits to SDPs for prac­ Situation Analysis approach can be tice (see "The training agenda for the re­ used to obtain a picture not only of search team," page 20). family planning services, but also of other Before the actual training of interviewers, related services. For example, recent modifi­ it is usually very helpful to hold a thorough cations of the data collection instruments orientation on the Situation Analysis ap­ have covered more fully reproductive proach and on managing the study for the health issues such as abortion (Senegal SA), principal investigators and study supervisors. sexually transmitted disease services The orientation should be for several days to (Botswana SA), and sterilization services a week. It should cover all aspects of the (Turkey SA). data collection process including training,

Situation Analysis study methodology • 8 locating SDPs, organizing and checking Most recent Situation Analysis studies are questionnaires, call-back procedures, and now used to examine selected aspects of re­ what to do if emergencies occur. productive health such as abortion, STDs, and HIV/ AIDS services. Others have used Programmatic uses of the Situation Analysis approach to examine Situation Analysis studies emergency obstetric care (Center for Popula­ The major users of the findings from a Situa- tion and Family Health, 1995; and Sloan et tion Analysis study are policymakers, donor al., 1995). For example, SDP staff can be organizations, program administrators, and asked about access to abortion services, and service providers at all levels (Askew and about questions they receive from clients Fisher, 1995). The standard analysis plan for concerning abortion. They also can be asked the data from a Situation Analysis study con­ about the availability of equipment, supplies, tains over 100 tables and graphs that typi­ and trained personnel to provide safe abor­ cally are generated from each study (see tion or emergency obstetric care services. Chapter 4), extensively discussed at a dis­ Similarly, clients can be asked if they ever semination seminar, and may ultimately go had an unwanted pregnancy, and if they into the first report. The information ob­ have, how they handled the pregnancy. This tained can be used for a variety of program­ approach has been used in a number of related purposes to: Situation Analysis studies (see Huntington et • Assess the quality of care provided to al., 1993a and Huntington et al., 1996b). clients by public and private service If a Situation Analysis study covers all clinics and by CBDs; SDPs in a geographic area such as a city or • Evaluate the extent to which reproduc­ country (see Mensch et al., 1994b for tive health services are integrated into NairobD, the weaknesses of any given SDP family planning programs; within the geographic area in terms of lack • Refine the estimates of staff training of staff, equipment, supplies, or other ele­ needs (both initial and refresher); ments can be identified easily and often cor­ • Examine the availability and use of in­ rected quickly. Also, of course, the entire formation, education, and communica­ system can be described accurately since all tion (lEC) materials; SDPs are included in the analysis. On the • Highlight equipment requirements, other hand, if a survey sample approach is particularly for clinical methods such taken to the selection of SDPs, it is possible as the IUD and sterilization; to describe the entire service provision sys­ • Guide the plans for facility renovation; tem in terms of probabilities but not in • Quantify the current contraceptive sup­ terms of the weaknesses of any given SDP. ply levels at service delivery points visited; A model for implementing Situation • Assess the functioning of the manage­ Analysis studies has emerged which includes ment information and logistics systems; participation by managers in each of the key • Assess barriers to access; study implementation phases in order to in­ • Provide data for policy formulation or crease understanding of the research process change; and use of the study results for program • Identify areas for initiating operations change. First, a planning or orientation research studies. meeting is held, attended by the researchers,

Situation Analysis study methodology • 9 the senior managers responsible for the the workshop is to obtain agreement on the SDPs to be visited, and the major users of programmatic implications of the data. the data (such as policymakers and do­ After the Data Interpretation Workshop, a nors). At this meeting, the Situation Analy­ final report is written that includes recom­ sis methodology and procedures are mendations for program improvement and explained in detail. In addition, the sampling change. The final report is presented at one plan is developed to reflect the needs of all or more Dissemination Workshops and the relevant family planning organizations in the results are discussed by the participants. Re­ country, the core data collection instru­ cent Situation Analysis studies in Senegal, ments are adapted to the specific service Burkina Faso, and Indonesia have focused delivery systems being analyzed, and the on disseminating the results not only at the managers agree on responsibilities for en­ national level but also at the regional level suring the research teams' access to the in order to achieve maximum involvement SDPs. Senior program managers continue of local-level program managers and in­ to be involved throughout the study in­ crease the probability that the results will be cluding in the training and field data col­ used for positive program change (Diop et lection phases. al., 1996). Once the data have been collected and processed, a Data Interpretation Workshop Impact studies and is held for the same group of managers, re­ Situation Analysis searchers, policymakers and donors to dis­ Impact studies build upon the basic Situa­ cuss the preliminary study results. Rapid tion Analysis design and meet the fourth ob­ data entry and production of frequency jective noted earlier. There are three tabulations of the variables, with some basic variations of impact studies that can be un­ cross-tabulations where necessary, are es­ dertaken. The first is the simplest and can sential for this workshop (see Chapter 4). more accurately be termed an "output" The rapid production of initial data is facili­ evaluation study rather than an impact tated by user-friendly computer programs study.3 The procedure would be to conduct such as Epi Info (Dean et al., 1990). The re­ two Situation Analysis studies, each of which sults are usually presented in the form of would use the same sample of SDPs. The bar charts for each variable. Bar charts are second study would be conducted approxi­ fairly easy for all audiences to understand mately three years or more after the first. and they appear to stimulate ready discus­ The objective would be to evaluate changes sion and a search for solutions to the prob­ that may have occurred as a result of pro­ lems that emerge. One of the basic purposes gram improvements. The "impact" of these of the Data Interpretation Workshop is to al­ low managers to see the preliminary data 3 See Bertrand et al., 1994, p. 19. Bertrand and col­ before a final report has been written and leagues outline a process of: any analysis or interpretation has been at­ INPUT-> PROCESS--> OUTPUT--> OUTCOME where the inputs, process, and outputs refer to tached to the data. In this way, data interpre­ project or program specific components and out­ tation becomes their responsibility, and not comes to larger, population-based "ultimate out­ that of the researchers. A major objective of comes" that are related to effect and impact.

Situation Analysis study methodology • 10 changes would be measured in terms of im­ couples who have been sampled and inter­ proved SDP subsystem potential to provide viewed in the geographic areas served by quality of care, and in the actual receipt of the SDPs (see Mensch et al., 1996). quality of care by clients (Miller and Frerichs, 1992-93; and Miller et al., 1996). Operations research and A second type of impact study would be Situation Analysis longitudinal and again require conducting Situation Analysis studies are closely linked two Situation Analysis studies in the same with operations research (OR) and indeed, sample of SDPs as well as creating a panel are an essential component of the OR pro­ of clients. In the first study, the reproductive cess. As defined by Fisher et al. (1991), the intentions of clients would be determined OR process has five basic steps: problem during exit interviews. These clients would identification and diagnosis, strategy selec­ form a panel and be reinterviewed approxi­ tion, strategy experimentation and evalua­ mately two or three years later. During this tion, information dissemination, and period, problems at the SDPs identified by information utilization. Situation Analysis the first Situation Analysis might be elimi­ studies have become one of the single most nated or at least reduced through some form important tools for gathering data necessary of service delivery intervention program.4 A for the first step of the OR process-prob­ second, follow-up Situation Analysis study lem identification and diagnosis. would then be conducted to determine the Situation Analysis studies identify and de­ extent to which SDP subsystem potential fine in considerable detail supply side con­ readiness and provision of quality of care straints to the delivery of services. Once had been improved. If the potential readi­ having defined the problem areas, OR stud­ ness and quality had been significantly im­ ies can then be designed and implemented proved, then the impact of this should be to test new approaches to overcoming the noticeable in the behavior of the panel with problem. The results from these studies are respect to their ability to meet their own re­ then disseminated and utilized for service productive intentions. Essentially, this type improvement. After the results have been of study examines the extent to which dif­ utilized, a second-round Situation Analysis ferences in contraceptive behavior can be at­ study can examine changes in the service tributed to differences in the quality and delivery environment that may have taken configuration of services provided at SDPs. place since the first study, and the impact The third type of impact study has a simi­ these changes may have had on the fertility lar purpose. It would seek to link a Situation behavior of clients. The second-round Situa­ Analysis to a population-based, KAP-type tion Analysis study also serves to identify study such as a Demographic and Health

Survey. All SDPs in the geographic area coy.. 4 If an intervention is not possible, then it would be ered by the population-based survey would necessary to select a geographic setting where be included in the Situation Analysis. The there is variation in family planning inputs, includ­ ing quality of services. In the absence of variation particular configuration and quality of ser­ it would not be possible to demonstrate a relation­ vices offered by the SDPs could then be re­ ship between quality of care, contraceptive use, lated to the contraceptive behavior of and fertility.

Situation Analysis study methodology • 11 FIGURE 2. Relationship between the operations research The interest generated by process and Situation Analysis this initial Situation Analysis study and its dissemination ef­ SA to - Select - Test - Disseminate - Utilize - SA to identify strategy strategy results results evaluate fort led to many requests for problems impact and identify new additional studies, initially in problems African countries, but later in Asian and Latin American countries. By late 1996, more than 35 studies had been com­ pleted or were being com- and define new problems that may have de­ pleted around the world and many more veloped or old problems that were not were at various planning stages. The utiliza­ solved. Thus, Situation Analysis studies not tion of Situation Analysis study findings has only start the process of operations research been documented in a number of case stud­ with problem identification and diagnosis ies, most recently for Burkina Faso (Popula­ and end that process by evaluating changes tion Council, 1996). and impact, they also initiate a new cycle of problem identification and diagnosis as Methodological issues shown in Figure 2. In the process of planning and conducting Situation Analysis studies, the methodology The diffusion of evolved as a result of three factors: (1) adap­ Situation Analysis tation to local interests and program The results from the first Kenyan study were components; (2) critical analysis by a larger provided quickly to program managers in number of researchers involved in the stud­ graphic format (Miller et al., 1989) which ies; and (3) a desire to explore possible so­ made the results easily understandable and lutions to continuing methodological issues greatly facilitated the dissemination of both and problems. Several methodological is­ the results and the methodology. The data sues, some recognized as early as the first proved useful to the managers of the Ken­ Kenyan study, have become more apparent yan family planning program who felt that and need to be addressed in the future. for the first time they had some understand­ These include: ing of the supply side of their program and • Positive bias of observation and could represent the program more accu­ interview rately to their own government and to out­ While the data collected with the "SDP side donor agencies. Some specific changes inventory" questionnaire are reason­ in curriculum design and administration ably unbiased, the observations of the were made in an attempt to solve problems provider-client interaction are quite in­ quickly. The data were also used to train se­ trusive and probably bias in a positive lected staff of the MOH and local universi­ direction the results obtained on qual­ ties in OR, and to design and implement ity of care. Responses from staff inter­ several OR studies aimed at solving the prob­ views are also probably biased in favor lems identified by the Situation Analysis study. of representing the SDP's operations in

Situation Analysis study methodology • 12 a more favorable light. These problems observed? This issue becomes impor­ have concerned the researchers from tant because new clients are often not the first study. Oile solution to this available at clinics on the day of the re­ problem is to spend more than one search visit, and if clients are less likely day at each SDP so that the presence to be present at lower quality SDPs, of the research team becomes more fa­ then the resulting observations of pro­ miliar and the behavior of providers vider-client interactions further bias the becomes more normative (Simmons resulting picture of the entire program and Elias, 1993). Another approach to in a positive direction. There is also the lessening the positive bias might be to issue of whether the various types of use "mystery" clients (Huntington and SDPs (for example, urban hospitals, dis­ Schuler, 1993b). trict health centers, or village health • Reliability of observations posts) should be weighted in terms of A key source of data from Situation client load or possibly catchment area Analysis studies comes from the obser­ population. vation of the provider-client interac­ • Applied research needs versus tion. An important concern with this theory testing data is its reliability. While observers As noted earlier, the original purpose are given extensive training, there ob­ of the Situation Analysis studies was to viously is some degree of variability describe the strengths and weaknesses between them. As part of the Situation of family planning programs. More re­ Analysis study in Turkey, two observers cently, the purposes of the study have recorded the same provider-client in­ expanded. Researchers in some coun­ teraction. A comparison of the re­ tries have wanted to answer a number sponses from the two observers of questions from a Situation Analysis revealed, overall, a very high degree of study for which it was not originally reliability (Huntington et a1., 1996a). designed. There seems to be a funda­ While this is encouraging, further mental tension between researchers methodological studies of this type who would like to utilize the data for need to be conducted. an analysis of correlates of service use • The number and representative­ dynamics and family planning manag­ ness of SDPs and observations ers who are most interested in a de- There are a number of important sam­ .scription of their program. Most often, pling issues associated with Situation Situation Analysis studies have been Analysis studies. First, there is the issue used for the latter rather than the of how many SDPs to include in the former purpose. sample. What type of SDP should be • Adaptation for routine manage­ included-only MOH SDPs or a mix ment and program monitoring with private SDPs? Should separate To date, Situation Analysis studies have samples be included for each type of been organized and implemented pri­ SDP? Also, within each SDP, how many marily as discrete research studies. provider-client interactions should be There is, however, a growing interest

Situation Analysis study methodology • 13 among MCH and FP managers in utiliz­ dressed, and a more standard set of instru­ ing Quality Assurance (QA) procedures ments, as well as data analysis plans, are be­ for routinely assessing and improving ing used. At the same time, several program operations (Katz et al., 1993). methodological problems not initially fore­ Although the Situation Analysis ap­ seen are receiving increasing attention and proach in its current form is not suit­ steps are being taken to improve the way in able for adoption as a QA procedure which data are collected. It is hoped that the (Askew, 1994), it is certainly possible strengthened methodology, based on both a to adapt it for such use. Studies in theoretically sound framework and field­ Kenya and Botswana have been testing tested research methods, will provide a ways in which elements of the Situa­ generally acceptable approach for assessing tion Analysis approach can be utilized family planning and reproductive health within routine management and MIS programs. procedures. And in several countries (Kenya, Burkina Faso, Senegal, Zimba­ References bwe, and Ghana) two Situation Analy­ Arends-Kuenning. M., B. Mensch. and M. R. Garate. sis studies conducted several years 1996. "Comparing the Peru service availability apart are being used to monitor pro­ module and situation analysis." Studies in Family Planning 27.1:44-51. gram changes over time. Askew, I. 1994. "Distinguishing between quality as­ surance mechanisms and quality assessment Conclusions techniques." Health Policy and Planning 9,3: In a very short period of time since the first 274-277. Askew, I. and A. Fisher. 1995. "Using operations re­ Kenyan study in 1989, the Situation Analysis search to guide family planning program devel­ approach to examining the supply side of opment and policy formulation in Sub-Saharan family planning has diffused rapidly Africa." Population Research and Policy Review throughout the world. The approach has 14:373-393. Bertrand. J., R. Magnani. and J. Knowles. 1994. become one of the key tools in diagnosing Handbook ofIndicatorsfor Family Planning the strengths and weaknesses of program Program Evaluation. The Evaluation Project, functioning, and operationalizing and Carolina Population Center. University of North assessing the concept of quality of care. The Carolina, Chapel Hill. North Carolina. approach also holds considerable promise Bruce. J. 1990. "Fundamental elements of the qual­ ity of care: A simple framework." Studies in as a methodology to evaluate the impact Family Planning 21,2:61-91. quality of care has on service utilization and Casterline, J.. ed. 1985. The Collection andAnalysis on the fertility behavior of clients. The stud­ ofCommunity Data: WFS Seminar on Collection ies conducted to date have been widely andAnalysis ofData on Community and Institu­ tional Factors. 20-23 June 1983, International used by program managers as a source of Statistical Institute. World Fertility Survey. information for improving and expanding Center for Human Services. 1988. Primary Health programs. As with any new approach, the Care Thesaurus: A List ofService and Support In­ methodology has evolved, developed, and dicators. Chevy Chase, Maryland. Center for Population and Family Health. Preven­ improved. The sample sizes have increased, tion of Maternal Mortality Network. 1995. "Situa­ new topics including abortion, STDs, and tion Analyses of emergency obstetric care: emergency obstetric care are being ad- Examples from eleven operations research

Situation Analysis study methodology • 14 projects in West Africa." Social Science and Huntington, D., B. Mensch, and V. Miller. 1996b. Medicine 40,5:657-667. "Survey questions for the measurement of in­ Cleland, J. 1973. "A Critique of KAP studies and duced abortion." Studies in Family Planning some suggestions for their improvement." Stud­ 27,3:155-161. ies in Family Planning 4,2:42-47. Katz, K, K Hardee, and M. Villinski. 1993. Quality Dean, A., J. Dean, A. Burton, and R. Dicker. 1990. ofCare in Family Planning: A Catalog ofAssess­ Epi Info, Version 5: A Word Processing, Database ment andImprovement Tools. Family Health In­ and Statistics Programfor Epidemiology on Mi­ ternational, Durham, North Carolina. crocomputers. USD Inc., Stone Mountain. Keller, A. 1991. "Management information systems Diop, N., A. Cerulli, and D. Sanogo. 1996. "Regional in maternal and child health/family planning dissemination of Senegal's Situation Analysis re­ programs: A multi-country analysis." Studies in sults: A promising way to maximize operations Family Planning 22,1:19-30. research utilization." Paper presented at Situation Kumar, S., A. Jain, and J. Bruce. 1989. "Assessing Analysis Managers' Utilization Meeting, Nairobi, the quality of family planning services in devel­ Kenya. oping countries." Programs Division Working Pa­ Fisher, A., J. Laing, J. Stoeckel, and J. Townsend. per No.2, Population Council, New York. 1991. Handbookfor Family Planning Operations Mensch, B., A. Fisher, I. Askew, and A. Ajayi. 1994a. Research Design, Second Edition. Population "Using situation analysis data to assess the func­ Council, New York. tioning of family planning clinics in Nigeria, Tan­ Fisher, A., B. Mensch, R. Miller, I. Askew, A. Jain, C. zania, and Zimbabwe." Studies in Family Ndeti, 1. Ndhlovu, and P. Tapsoba. 1992. Guide­ Planning 25,1:18-31. lines and Instrumentsfor a Family Planning Mensch, B., R. Miller, A. Fisher, J. Mwita, N. Situation Analysis Study. Population Council, Keyonzo, F. Mohamed Ali, and C. Ndeti. 1994b. New York. "Family planning services in Nairobi: A Situation Fisher, A. 1993. "Family planning in Africa: A Sum­ Analysis of City Commission clinics." Interna­ mary of recent results from operations research tional Family Planning Perspectives 20,2:48-54. studies." In Conference Proceedings and Papers, Mensch, B., M. Arends-Kuenning, and A. Jain. 1996. Africa OR/FA Project, Africa OR/TA Project, End "The impact of the quality of family planning of Project Conference, Nairobi, Kenya. services on contraceptive use in Peru." Studies in Freedman, R. 1974. "Community-level data in fertil­ Family Planning 27,2:59-75. ity surveys." World Fertility Survey Occasional Miller, R., 1. Ndhlovu, and M. Gachara. 1989. A Papers No.8, London, World Fertility Survey. Situation Analysis ofthe Family Planning Pro­ Frerichs, R. 1989. "Simple analytic procedures for gram ofKenya: The Availability Functioning and rapid microcomputer-assisted cluster surveys in Quality ofMOH Services. Population Council and developing countries." Public Health Reports Kenya Ministry of Health, Nairobi, Kenya. 104,1:24-34. Miller, R., 1. Ndhlovu, M. Gachara, and A. Fisher. 1991. "The situation analysis study of the family Frerichs, R. and Khin Tar Tar. 1989. "Computer-as­ planning program in Kenya." Studies in Family sisted rapid surveys in developing countries." Planning 22,3:131-143. Public Health Reports 104,1:14-23. Miller, R., and R. Frerichs. 1992-93. "An integrated Huntington, D., B. Mensch, and N. Toubia. 1993a. approach to operations research for strengthen­ "A new approach to eliciting information about ing family planning programs: A case example induced abortion." Studies in Family Planning in Kenya." International Quarterly ofCommu­ 24,2:120-124. nity Health Education 13,3:183-199. Huntington, D. and S. Schuler. 1993b. "The simu­ Miller, R., K Miller, 1. Ndhlovu, J. Solo, and O. lated client method: Evaluating client-provider Achola. 1996. "A comparison of the 1995 and interactions in family planning clinics." Studies 1989 Kenya Situation Analysis study findings." in Family Planning 24,3:187-193. Paper presented at the meeting Kenya: Situation Huntington, D., K. Miller, and B. Mensch. 1996a. "The Analysis Study ofthe Family Planning Services. reliability of the situation analysis observation Population Council and Division of Family guide." Studies in Family Planning 27,5:277-282. Health, Ministry of Health, Nairobi. Also pre-

Situation Analysis study methodology • 15 sented at the APHA Annual Meeting, November Ebert Program of the Population Council, 1996, New York. New York. Population Council, Africa Operations Research and Simmons, R. and C. Elias. 1993. "The study of client­ Technical Assistance Project II. 1996. Case Study provider interactions: A review of methodologi­ Summary Report: A Situation Analysis ofthe Na­ cal issues." Programs Division Working Paper tional Family Planning Program in Burkina Faso. No.7, Population Council, New York. Population Council, Dakar, Senegal. Wilkinson, M. 1991. "The DHS service availability Ross, J. and E. Frankenberg. 1993. Findingsfrom questionnaire." Paper presented at the meeting Two Decades ofFamily Planning Research. on Measuring the Influence of Accessibility of Population Council, New York. Family Planning Services in Developing Coun­ Sloan, N., C. Quimby, B. Winikoff, and N. tries, National Academy of Sciences Committee Schwalbe. 1995. Guidelines and Instrumentsfor on Population, Washington, DC. a Situation Analysis ofObstetric Services. The

Situation Analysis study methodology • 16 Chapter 2

Conducting the study

Ethical issues in the conduct of sons with impaired or diminished au­ Situation Analysis studies tonomy; Situation Analysis studies require interviews (2) benrificence, which is the ethical of clients and providers, as well as observa­ obligation to maximize benefits and tions of provider-client interactions. These minimize harms or wrongs; study procedures potentially carry some (3) non-maleficence, which means risks for the study subjects unless mecha­ "do no harm"; and nisms are established to protect the subjects. (4) justice, which requires that subjects Institutions planning to carry out Situation in studies are treated equally, and Analysis studies or related technical assis­ studies are designed so that the sub­ tance activities should consider the relevant jects of study are also the beneficia­ local laws and regulations that govern the ries of the study...." review of research proposals and proce­ All of these concerns are relevant in a dures. In many settings, special committees Situation Analysis study, and should be review research proposals to ensure that discussed openly and completely with local issues of confidentiality, privacy, incentives, researchers and managers, and with field informed consent, and other general research staff during training. The full concerns will be handled in a way that is importance of privacy, informed consent, ethical and protects the study subjects from and protection of subjects needs to be com­ any harm. municated to all involved with the study, The Council for International Organiza­ and researchers need to practice how they tions of the Medical Sciences (CIOMS), in af­ communicate these messages to the study filiation with the World Health Organization, subjects and to others. addresses ethical issues of concern to the in­ Confidentiality and privacy. Informa­ ternational research community. The four tion obtained from providers and clients as guidelines of the CIOMS for research with human subjects are1: "(1) Respectforpersons, which includes 1 From TL. Beauchamp, and J.L. Childress, Prin­ both autonomy, or the respect for the ciples ofBiomedical Ethics, 2nd Edition, Oxford self-determination of those who are University Press, 1983, as summarized in K. Ringheim, capable of deliberating about their 1995, "Ethical issues in social science research with special reference to sexual behaviour research," personal goals, and protection of per- Social Science andMedicine, 40,12:1691-1697.

Conducting the study • 17 part of a Situation Analysis study must be the client ill-at-ease, particularly if the kept confidential and private, as part of the client's responses to questions can be heard non-maleficence or "do no harm" gUideline. by others. It is very important to conduct in­ The identity of study subjects must be pro­ terviews in a private setting where the client tected by the researchers, which is usually can feel at ease (this also increases the done by identifying subjects with a code validity of the information collected). Also, rather than a name and address. Also, the physical examinations are sometimes researchers should be careful to control or uncomfortable and embarrassing for clients. remove any variables that could be used to Situation Analysis study observers should al­ identify individual interviewees. ways obtain the consent of the client to In a few countries, the Situation Analysis be present during the examination. The study design calls for a panel of clients who client's desire for privacy in these settings will be followed over time and re-inter­ must be respected. viewed. In panel study designs of this type, Informed consent. The principle of re­ clients must be asked at the end of the inter­ spect for persons establishes the right of view if they are willing to be on the panel, if both clients and providers to hear about the they are willing to have their names and ad­ nature of the study, about any risks and ben­ dresses recorded, and if they are willing to efits associated with their participation, and be re-interviewed at a later point in time. At that they can withdraw from the study at this point, study subjects must be made any time. Clients must also be informed that aware that follow-up contacts may take they can receive all the services of the place in their homes, where a spouse or health facility whether or not they partici­ other family member may learn that the in­ pate in the study. These issues should be terviewee has been obtaining clinical ser­ presented in language that is easily under­ vices such as family planning or possibly stood, and the subject must freely and vol­ treatment for an STD. If the client does not untarily agree to her inclusion in the study. wish to be in the study, then the researchers True "informed consent" also requires that must honor this decision; only if she agrees the subject is given the opportunity to ask can her name and address be recorded. questions about the study before consenting. However, because this information so di­ Field researchers should be given informa­ rectly identifies clients, the names and ad­ tion about how to handle and direct ques­ I' dresses must be removed from the rest of tions from study subjects about family the questionnaire and stored separately in a planning and other health related matters. locked cabinet with restricted access. The Clear guidance must be provided to field re­ only identifier on the actual questionnaire searchers to emphasize the purely voluntary should be a code number. nature of all participation. It is also impor­ Confidentiality extends not only to the tant to note that consent should only be ob­ client's identity but also to the exposure a tained when the client is not under duress, client experiences in the course of the study. in pain, medicated with consciousness alter­ Both the observation and the exit interview ing drugs, or in need of acute care. Clients deal with highly sensitive issues of family with any of these conditions should not be life and sexual behavior, which might make included in the study since their condition

Conducting the study • 18 precludes their ability to give thoughtful at­ developed and discussed during training by tention to their consent. MOH officials of the country. The benefits to be derived by both clients Of course, interventions of this type and providers from the research are mainly can influence the research results, but in social: the information will be used for de­ such instances the safety of the client veloping improved program policies and outweighs the needs of the researchers and practices. We believe that the Situation managers. When clients' needs and Analysis procedures involve no additional researchers' needs clearly conflict, the re­ risk for clients beyond the social and psy­ search needs should be compromised, as chological risks that may be associated with suggested by the Helsinki Declaration. seeking medical consultation for a sex-re­ These cases should also be carefully lated matter. While it is possible that there documented. Field observers are trained could be some additional risk to a client accordingly in Population Council-assisted from a provider who is nervous about being Situation Analysis studies. observed, we believe that the more likely In less extreme cases observers may face occurrence is for the provider to be espe­ a more difficult and less obvious ethical is­ cially careful during the observation and to sue. Most researchers would probably agree attempt to provide services of as high a that in extreme cases where clients are quality as she is capable of providing. clearly at some risk, intervention by the ob­ Observer's responsibility to the server is necessary. However, these cases are client's welfare. The Helsinki Declaration relatively rare. The more common occur­ of 1964, which addresses ethics in biomedi­ rence observed in almost all Situation cal research, holds that "in research on man, Analysis studies is to find a vast array of the interest of science and society should somewhat less serious service quality issues. never take precedence over considerations Indeed, it is usually the case that observers related to the well-being of the subject." Oc­ will see a large number of mistakes, lapses, casionally, Situation Analysis observers wit­ and misinformation transmitted, and inter­ ness gross violations of acceptable provider viewers will find that clients may not know behavior that puts the client at risk of mor­ crucial information about their selected bidity. For example, if a provider drops an contraceptive. In fact, it is just this sort of IUD on the floor, picks it up, and attempts information that the Situation Analysis is to insert it in a woman without sterilizing it, designed to uncover so that needed policy she exposes the woman to a risk of infec­ and program changes can be made. Should tion. In one case, a provider was observed an intervention of some type be attempted wiping her hands on the drapes before she with every service delivery situation that is conducted a physical examination. In such less than optimal? Clearly doing so would cases of obvious violation of standard accept­ prove so intrusive and detrimental to able procedures, the Situation Analysis study rapport with staff as to ruin the possibility observer may have a responsibility to inter­ of gathering useful information for program vene to protect the client from potential and policy decision-making and thus would harm. A list of potential situations that might greatly lessen the ability to make needed call for some form of intervention should be improvements. It is important to discuss

Conducting the study • 19 fully with relevant local authorities the introduction to the research objectives, inter­ potential ethical issues that may arise during viewing and observing, ethical issues, and the implementation of a Situation Analysis a detailed review of each question in every study, and the type of behaviors by provid­ questionnaire so that all team members ers that may require some form of interven­ fully understand each question's meaning, tion by the study observers and interviewers. how to ask the question and how to record the answer. Considerable time is then Establishing objectives and spent on "role playing" both the interviews reviewing questionnaires and the observations, with the trainees tak­ The first step in conducting a Situation ing turns to act as the interviewer or ob­ Analysis is to hold a planning or orientation server and as the SDP staff person or a meeting for the researchers, the senior manag­ client. Role playing gives each team member ers responsible for the SDPs to be visited, and a chance to practice asking questions and the major users of the data (such as policy­ recording answers. Initially, trainees fre­ makers and donors). At this meeting, the SA quently record responses differently. Discus­ methodology and procedures are explained in sion of these instances provides an detail, and the objectives of the study are dis­ opportunity to clarify definitions and under­ cussed. After these points are established, the standings. As the training program questionnaires are carefully reviewed for their progresses, trainees develop confidence with appropriateness. The objectives of the study the data collection instruments and probably should suggest to the group what sort of infor­ will memorize certain sections. Reliability mation will be required, and a set of key in­ between observers increases. In addition to dicators can usually be drawn up at this role playing, the training session includes at point (see Chapter 4 for suggested indica­ least two days spent at SDPs so that team tors). These indicators should guide any re­ members can actually practice interviewing, visions to the questionnaires. observing, and taking an inventory. See the In addition, the sampling plan should be sample schedule of training activities out­ developed to reflect the needs of all relevant lined in Table 1. family planning organizations in the country, The last day of training is spent planning and the managers should agree on responsi­ for the fieldwork. Each team meets together bilities for ensuring the research teams' ac­ and fmalizes the following fieldwork issues: cess to the SDPs. In addition, the program • the list of SDPs to be visited; managers should continue to be involved • the schedule of visits over the field- throughout the study including in the train­ work period; ing and field data collection phases. • transportation; • accommodation; The training agenda for the • supervisory visits; research team • storage of completed and resupply of The next step is to hold a training for the fresh data collection instruments. research team, which usually takes at least Fieldwork should begin a week after ten days. The training consists of a broad this final session, giving the study planners

Conducting the study • 20 TABLE 1. S~mple training schedule Day Activities One Introductions. Training plans. Background to SA studies. Concepts of reliability, validity, and some pitfalls in the data collection process. Some field experiences from other SA studies. Overview of the instruments.

Two Review of the Observation Guide. Review of the FP Client Exit Interview. Review of the Staff Interview.

Three Review of the Inventory. Review of the MCH Client Exit Interview. Plenary meeting to discuss issues arising from instrument reviews. .J Guidelines for conducting interviews. Four Break into specialized groups of researchers and nurse/midwives. Review administration of specific instruments for each group. Role playing.

Five Continue role playing. Plenary meeting to discuss role playing experiences.

Six Fieldwork at selected SDP sites. Each team to practice administering the data collection instruments.

Seven Continue fieldwork at selected SDP sites.

Eight Review of fieldwork experiences and role playing. Review of supervisory roles with Team Leaders/Supervisors.

Nine Role playing.

Ten Each team plans its travel logistics. Plans discussed in group and modified as necessary. Administrative and financial issues.

time to revise and print the new question­ tant factor in the successful execution of the naires. After this is completed and the instru­ fieldwork. This means that the team mem­ ments are distributed to the field teams, the bers have to be sensitive to each other's schedule of visits to SDPs can begin. needs and points of view. Where difficulties arise, the supervisor may be responsible for Role ofthe Teatn Leader/ facilitating the process of problem-solving. Supervisor Above all, remember that each team mem­ The team leader will be called upon to as- ber has different resources and abilities, and sume several roles while in the field. He/she these should be tapped to make the field should be prepared to assist at all times with experience successful. Some issues that regards to field operations. High morale need attention while in the field are dis­ among the team members is a very impor- cussed below:

Conducting the study • 21 • Transportation arrangements logical order according to type and The Team Leader has to make sure that date of visit to the SDPs. transportation is available and ready • Permission from local authorities every day to take the interviewers to Permission to visit SDPs should be the field. The driver, who becomes part obtained from local authorities. The of the field team, has to receive clear Team Leader should organize this. At instructions on where and when to go. the SDPs themselves, the team mem­ Public transportation may be used as bers should be introduced to the SDP an alternative if appropriate but this is staff and the purpose of the study usually not very satisfactory except should be explained briefly. The possibly in urban areas. Leader will generally be responsible • Check on completion of for this function. instruments • Disbursing ofper diems and other On a daily basis, the supervisor checks money matters the entries to the data collection instru­ Each team evolves its own method of ments to verify consistency and accu­ organizing for meals and other com­ racy of the data collected. This will mon needs. Generally, per diem ar­ include inaccurate recordings of the in­ rangements for the team will be terviews. If the reviews are done as a handled through the Leader. group, it provides a training experience The Team Leader usually keeps for the team members. This will be some money for fuel and other vehicle particularly important during the first expenses. It is important that expendi­ few days of the study. ture receipts are obtained and kept For all of the instruments, some properly in an orderly manner. Another information on the cover page can be related issue is for the Team Leader to filled in before a visit to the SDP is check that the driver keeps a proper made. This is encouraged since it daily mileage log book. saves time and allows for prior • Keeping a daily summary record planning to make sure that all details At the end of every day, the Team are consistent. Leader reviews with the other team To maintain a sufficient supply of members the activities of the day and instruments, the Team Leader has to then writes a brief report (usually keep in contact with the Principal about 112 to 1 page). The report may Investigator at the head office. include events at the SDP that made Normally, a date for a field visit by the the data collection process unusual­ Principal Investigator will be arranged perhaps too easy or too difficult. The during the training sessions. report is a summary of the experiences • Safekeeping of the questionnaires of the team and is valuable information The Team Leader needs to organize for interpreting the research results. the safe keeping and proper storage • Keeping contact with the head office of instruments, both used and unused. If the team experiences unusual diffi­ The instruments need to be kept in a culties or is in doubt about certain is-

Conducting the study • 22 sues, the head office or supervisor begins observing the interaction between should be contacted immediately. family planning clients and the provider(s) at the start of the day. Later, this person will The research team and also help one of the other team members to a typical day complete the inventory of equipment. The As noted in the previous chapter, the num­ social scientist is usually responsible for cli­ ber of research teams and supervisors used ent exit interviews and staff interviews. He/ in a study depends on the number and ac­ she may also help with collecting informa­ cessibility of SDPs, the objectives selected, tion on clinic records, reporting, and service and resources available. Usually between 5 statistics. Both team members are respon­ to 10 teams will spend about six weeks visit­ sible for interviewing MCH clients. ing a total of 150 to 300 SDPsj each team At the end of the day, the Team Leader will visit 25-30 SDPs. should review with the other team members Prior to arriving at the SDP, perhaps dur­ the visit to the SDP. The Team Leader should ing the previous evening, the team members then write a brief (liz to 1 page) report of should make sure that the "standard codes" the visit, noting any unusual circumstances for identifying the type and location of the or occurrences that are important but that SDP to be visited have been agreed upon, will not be apparent from the data collection and possibly entered in advance on the instruments. cover and second pages for each instrument In addition, the Team Leader must also to be used. The codes for the type of SDP, review every instrument to ensure that all type of sector and type of locality should be responses are correctly recorded. This step discussed with the Head of the SDP and is sometimes difficult to complete at the end should be consistent for every instrument of a long day, but its importance cannot be used at that SDP. Moreover, the codes for overemphasized. If the questionnaires are each staff member and client must be care­ missing information, the quality of the data fully recorded for each interview and obser­ is highly compromised, and the results will vation, and must match across instruments. be less informative, and sometimes even un­ The Team Leader should assign these codes usable. Thus, the cost of missing data is for staff and clients after arriving at the high, and it should be strictly avoided. The SDP. These "linking" variables are extremely check for missing data at the end of a day in important in the data analysis, so these the field may be tiring, but it represents the codes should always be checked thoroughly last opportunity to complete any information by the Team Leader. See Chapter 3 for that is missing. more information. The team should always arrive at the SDP Tips for conducting a before the official opening time. This is nec­ good interview essary in order for them to observe what The objective of any SA is to collect the happens when the SDP opens and, of most accurate information possible. Collect­ course, if it opens on time. ing information through interviews is not al­ As also noted in the previous chapter, the ways easy and requires an ability to ask team member with clinical training typically questions clearly and to listen carefully to

Conducting the study • 23 the answers. The objective of an interview is dent as much time as possible to an­ to get the opinions and ideas of the person swer your questions. being interviewed. It is very important to be • Circle the number on the question, tick neutral when interviewing a person. Do not the box, or write the number that cor­ try to indicate that there is one correct an­ responds to the answer given by the swer. The only answers that are correct are respondent. Circle or tick only one an­ those given by the person being inter­ swer unless the question clearly indi­ viewed. Here are some tips for conducting a cates that more than one response can good interview: be given, in which case circle or tick • Always introduce yourself in a friendly the relevant categories. and pleasant way. • If there are any difficulties with a par­ • Be sure to emphasize the voluntary ticular question or something unusual and confidential nature of the inter­ happens, such as the respondent has view. If the person refuses to be inter­ to leave suddenly, write what hap­ viewed, politely end the interview and pened in the margin of the question­ go to another person. naire or on the back. At the end of the • Never change the wording of the ques­ day explain to the Team Leader what tions. Ask each question in exactly the happened. way it is written on the questionnaire. • Sometimes you will be required to fill Use a neutral voice. Do not try to lead in a response for "Other: " on the the respondent to one answer or an­ questionnaire. Write clearly and simply. other. Do not suggest answers to the Use the back of the questionnaire if respondent. Let the respondent answer you need more space but be sure that for herself/himself. you identify the question number to • If you do not understand the answer to which your responses apply. a question, ask the respondent to re­ peat the answer. But, do not "lead" the Tips for conducting a respondent in such a way that you sug­ good observation gest an answer. In a neutral way ask The observation of client-provider interac- the respondent: "Can you explain a tions provides most of the information little more? Take your time, there is no regarding how a client is counseled, ex­ hurry." amined, and provided with a method. • If the respondent does not understand The person doing the observation should al­ a question, repeat the question slowly ways be medically trained and highly expe­ and clearly. If the respondent still does rienced in providing family planning not understand the question, you may services. The most appropriate observers have to restate it in different words­ have normally been female nurse-midwives but be very careful not to change the with several years of family planning experi­ meaning of the question. ence who also train others in family • Do not push the respondent or act as if planning; their training experience ensures you are in a hurry. Give the respon- that they are able to view an interaction

Conducting the study • 24 critically, and will be familiar with all of the should do everything possible to make her­ provider behaviors listed in the observation self unobtrusive. instrument. Before the consultation begins, the pro­ The observation guide is designed so that vider should ask the client whether it is ac­ the observer ticks boxes or circles numbers ceptable for the observer to be present. If that describe what she has seen. Because possible, the observer should sit in the back­ there is no fixed order for each consultation ground so that she is not directly in eye con­ it is essential that the observer learns the tact with either the provider or the client. structure of the observation guide so that She should wear appropriate clothing (in whenever she sees a particular action or some cases observers wear their own nurs­ hears a specific issue being discussed she ing uniforms) and have a pleasant smile on knows exactly where to mark the guide. In her face. She should also keep her paper some cases it may be necessary to remem­ and pen resting in her lap and be discreet ber what happened and to mark the guide when she notes down an observation. after the consultation is finished. Very occasionally the observer may see a Before the first consultation, the observer provider doing something that is potentially must get the provider's permission to sit in dangerous to the client. For example, the and observe the client-provider interaction. provider may be using unsterile equipment Normally this is not a problem, but it is im­ when doing an examination, inserting an portant to assure the provider that you are IUD, or administering an injectable. During not evaluating her competence. There can the training, a list will be drawn up of situa­ be problems if the observer is known to the tions the Ministry of Health feels are in clear provider, either as a supervisor or a col­ violation of safe practice and which, if seen league, so every effort should be made to by the observer, should be stopped. (See ensure that this does not happen. the earlier section on ethical considerations, The providers should also be told that the page 17.) research observer cannot participate at all At the end of the consultation, the ob­ during the consultations. The provider server should follow the client away from should not ask the research observer for her the provider and ask if she would mind be­ opinions or advice, except in extremely seri­ ing interviewed. If she agrees, then the ob­ ous situations; the provider should be re­ server should introduce the client to the quested to behave as if the observer were social science interviewer and give the ob­ not present. servation guide / exit interview instrument to The observer will have to be seated fairly the interviewer. It is very important that the close to the client and provider to be able to instrument used for the observation of the see and hear exactly what goes on. More­ client-provider interaction be handed to the over, her presence is definitely going to af­ social science interviewer (see Chapter 3). fect the interaction, probably by making both the client and provider more self-con­ After data collection scious and aware of what they are saying Data collection can usually be completed in and doing. Consequently, the observer four to six weeks for a national Situation

Conducting the study • 25 Analysis study. At the end of data collection, lection process. Any unusual circumstances it is extremely important to debrief with the should be noted. supervisors and interviewers. The principal See Chapter 4 for information on how to investigator and the key program managers proceed with the entry, cleaning, analysis, and administrators should meet with the re­ and reporting of the data. search teams and review the entire data col-

Conducting the study • 26 Chapter 3

Instruments and question-by-question guides

This chapter contains the Situation Analysis on how to administer each question, they instruments: should be read in conjunction with the in­ • Inventory for Facilities Available and struments during training. Services Provided at the Service Deliv­ Several questions are common to all the ery Point (SDP) instruments, and are not discussed directly • Observation Guide for Interaction in the question-by-question guides. These Between Family Planning Clients and questions occur on the cover pages of each Service Providers instrument, and are particularly important in • Exit Interview for Family Planning data analysis. They include: Clients • Health facility code • Interview for Staff Providing Family • District code Planning/Reproductive Health Services • Village/town code at the SDP • Type of health facility • Interview for MCH Clients Attending • Type of sector the SDP • Locality Each question on the instruments is • Study client number marked with a suggested variable name in • Study staff number curly brackets:{ }. These variables would The codes for health facility, district, and not appear on the questionnaires used in village/town should all be agreed upon be­ the field, but they would be used during fore fieldwork begins. If possible, these lists data entry and analysis. The variable should be copied .and sent out with the re­ names are based on the question numbers search teams for reference during data col­ (rather than the content of questions) be­ lection. The information on type of facility, cause this method of naming has proved to sector, and locality can be determined at the be the easiest to use during data analysis. SDP, but these responses should match See the section on data entry and cleaning across the inventory and all observations, (page 157) for more information on staff interviews, and exit interviews that are variable names. performed at the same SDP. Each instrument is followed by a ques­ The study client number and study staff tion-by-question guide that explains the pur­ number require some coordination on the pose and details of each question. These part of the Team Leader. These numbers are guides are geared toward the data collector, intended to uniquely identify staff and cli­ and because they give essential information ents at a particular SDP. For example, the

Instruments and question-by-question guides • 27 first SDP visited might have three service clients can be linked with observations. providers working that day. These providers When the next SDP is visited, the staff iden­ should be numbered 1 to 3 at the start of tification numbers can again start from 1. Be­ the day. If the first provider is interviewed, cause this process can become confusing, the study staff number "I" would be entered only the team leader should assign study staff on the staff interview cover sheet, and if she and client numbers, and check carefully at the is observed with a client, the same number end of the day that they are coded correctly. would be entered on the observation cover Sometimes clients and providers are con­ sheet. Likewise, if that provider is observed cerned about being identified individually with four clients, then those four clients on the questionnaires and observation. would be numbered 1 to 4, and this same However, these study numbers are used number would be entered in the cover only to link information between instru­ pages of the observation and client exit in­ ments, never to identify individuals. The terview. If the staff member "2" is observed names of clients and staff are never written with three clients, they should also be num­ down, and no further identification of indi­ bered 1 through 3, etc. In this way, staff and viduals is required.

Instruments and question-by-question guides • 28 Inventory

The purpose of this instrument is to assess has detailed information on how to com­ the readiness of an SDP to provide services. plete each question. It inventories the services available, makes a The codes presented in brackets {} in complete list of all equipment, supplies, ma­ this instrument are suggested variable names terials, and commodities in working order, for each question or tick mark. These names and it assesses the functioning of several are referred to in the analysis plan (beginning subsystems, including physical infrastructure, on page 162). Keep in mind, however, that staffing, IEe materials, logistics, manage­ they would not appear on the actual ques­ ment, supervision, and recordkeeping. The tionnaires used by researchers in the field. question-by-question guide to the inventory See following pages for instrument.

Inventory • 29 Country Name Situation Analysis Study Questionnaire number: {liD}

Inventory for Facilities Available and Services Provided at the Service Delivery Point

INSTRUCTIONS TO DATA COLLECTOR: This inventory should be completed by observing the facilities that are available and through discussions with the person in charge of MCH/family planning on the day of the visit. In all cases you should verify that the items exist by actually observing them yourself - if you are not able to observe them, then code accordingly. Remember that the objective is to identify the equipment and facilities that currently exist and not to evaluate the performance of the staff or clinic. For each item, circle the response or describe, as appropriate.

Health facility visited (name): {HFNAME} Health facility code: {HFCODE} District (name): {DISTNAME} District code: {DISTCODE} Village/town (name): {TOWNNAME}

Village/town code: {TOWNCODE}

Date of visit: Day _ Month _ Year _ {DATE}

Type of health facility: {TYPE} Type of sector: {SECT} 1 = Referral Hospital 1 = Government 2 District Hospital 2 FPA 3 Primary Hospital 3 = Mission 4 Rural Health Center 4 Private 5 Maternity 5 Other 6 = Health Post 7 = Pharmacy Locality: {LOC} 8 = CBD 1 = Rural 9 Other 2 = Urban

Name of observer: ------Signature of team leader: _

Inventory • 30 Accessibility

ASK 1. What is the official opening time for this health facility? {11}

am / pm

OBS 2. At what time did the first family planning client arrive today? {12}

am / pm 98 No family planning clients 99 Not observed

OBS 3. At what time was the first family planning client seen today? {13}

am / pm 98 No family planning clients 99 Not observed

OBS 4. At what time was the last family planning client seen today? {14}

am / pm 98 No family planning clients 99 Not observed

ASK 5. What is the official closing time for this health facility? {15}

am / pm

ASK 6. How many days per week are family planning services offered at this health facility? {16}

days per week

OBS 7. Is there a sign announcing that FP services are available? {17}

1 Outside building 2 Inside building 3 Both inside and outside building 4 No sign visible

Inventory • 31 ASK 8. Is (read 1 - 17) usually available to A. Tick if available at B. Tick if available clients at this MCH/FP unit or elsewhere MCH/FP unit elsewhere in facility in the health facility?

1. Family planning {ISA1} {ISBl }

2. Antenatal care {ISA2} {ISB2}

3. Maternity care/delivery services {ISA3} {ISB3}

4. Postnatal care {ISA4} {ISB4}

5. HIV/AIDS counselling/IEC {ISA5} {ISB5}

6. HIV/AIDS testing {ISA6} {ISB6}

7. Other STD counselling/IEC {ISA7} {ISB7}

8. Other STD diagnosis {ISAS} {ISBS}

9. Other STD treatment {ISA9} {ISB9}

10. Child immunization {ISA1O} {ISB10}

11. Child growth monitoring {ISA11} {ISBll }

12. Infertility consultation {ISA12} {ISB l2}

13. Oral rehydration therapy {ISA13} {ISB l3}

14. Treatment of incomplete abortion {ISA14} {ISB14}

15. Nutrition counselling {ISA15} {ISB15}

16. Curative services - client {ISA16} {ISB l6}

17. Curative services - child {ISA17} {ISB l7}

Inventory • 32 Infrastructure aBS 9. On the day of the visit, does the MCH/FP unit have Tick if present the following:

1. Piped running water {19X1 }

2. Electricity {19X2}

3. Working toilets I latrines available for clients {19X3}

4. Sufficient seating for clients {19X4} 5. {19X5} 6. {19X6}

Staffing

ASK 10. How many (read ASK 11 . How many 1-7) are assigned to (read 1-7) are on duty work full time at this today? MCH/FP section?

1. Medical doctor Number: {110X1} Number: {111 X1}

2. Nurse Number: {110X2} Number: {111 X2}

3. Nurse-midwife Number: {110X3} Number: {111X3}

4. CBD Number: {110X4} Number: {111X4}

5. MCH assistant Number: {110X5} Number: {111 X5}

6. Number: {110X6} Number: {111 X6}

7. Number: {110X7} Number: {111 X7}

Inventory' 33 IEC materials and activities

OBS 12. Which IEC materials on A. Tick if B. Tick if C. Tick if the following subjects are flip chart brochure/ posters available in the MCH/FP available pamphlet available unit? available

1. Family planning {112A1} {112B1} {112C1 }

2. Antenatal/postnatal care {112A2} {112B2} {112C2}

3. Delivery services {112A3} {112B3} {112C3}

4. HIV/AIDS {112M} {112B4} {112C4}

5. Other STDs {112A5} {112B5} {112C5}

6. Child welfare {112A6} {112B6} {112C6}

7. Nutrition {112A7} {112B7} {112C7}

OBS/ASK 13. Was a "health talk" (group lecture or discussion with clients) held today? {113} 1 = Yes 2 = No (to q. 15) 98 = Don't know (to q.15)

OBS/ASK 14. (If yes) Which topics did Tick if topic 'included the health talk include?

1. Family planning {114X1 }

2. Antenatal care {114X2}

3. Maternity carel delivery services {114X3}

4. Postnatal care {114X4}

5. HIV/AIDS {114X5}

6. Other STDs {114X6}

7. Child immunization {114X7}

8. Child growth monitoring {114X8}

9. Infertility consultation {114X9}

10. Oral rehydration therapy {114X10}

11 . Treatment of incomplete abortion {114X11 }

12. Nutrition counselling {114X12}

13. Curative services - client {114X13}

14. Curative services - child {114X14}

15. Breastfeeding {114X15}

16. Other: {114X16R} {114X16}

Inventory· 34 Medical examination facilities

aBS 15. Are the following conditions present in Tick if present the examination area?

1. Auditory privacy {115X1 }

2. Visual privacy {115X2}

3. Cleanliness * {115X3}

4. Adequate light* * {115X4}

5. Adequate water* ** {115X5}

* "Cleanliness" means floors swept and mopped at the start of the day, no dust on window sills or tables.

** "Adequate light" means functioning electric light or sufficient natural light.

*** "Adequate water" means a sufficient quantity of clean water for washing hands and equipment.

Inventory· 35 Equipment and commodities inventory

OBS 16. Tick if the following types of equipment are available Tick if available and working in the MCH/FP unit, and/or in the stockroom for MCH/FP services.

1. Sterilizing equipment in MCH/FP unit {116X1 }

2. Sterilizing equipment outside MCH/FP unit (shared) {116X2}

3. Angle poise/gynecology lamps/torch {116X3}

4. Blood pressure machines {116X4}

5. Adult weighing scale {116X5}

6. Child weighing scales {116X6}

7. Scissors {116X7}

8. Antiseptic lotions {116X8} 9. Stethoscopes {116X9}

10. Refrigerator for EPI (immunization) {116X10}

11. Examination couch {116X11}

12. Thermometer {116X12}

13. Needles {116X13}

14. Syringes {116X14}

15. Microscope {116X15}

16. Cotton wool {116X16}

17. Gauze {116X17}

18. Dettol {116X18}

OBS 17. Count the number of the following types of Count equipment available and working in the MCH/FP unit, and/or in the stockroom for MCH/FP services.

1. Sponge holding forceps Number: {117X1}

2. Uterine sounds Number: {117X2}

3. Specula Number: {117X3}

4. Tenacula Number: {117X4}

5. Non-disposable gloves (number of pairs) Number: {117X5}

6. Disposable gloves (number of pairs) Number: {117X6}

Inventory • 36 ASK 18. Does the OBS 19. (If method is ASK 20. (If method is MCH/FP unit usually provided) usually provided) usually provide Physically check Has there been each of the and tick if any stock-out in following commodities the last six contraceptive available today. months? methods? (Tick if yes) (Read 1-9 and tick if provided)

1. Combined pill {118X1} {119Xl } {120Xl }

2. Progestin-only {118X2} {119X2} {120X2} pill

3. IUD {118X3} {119X3} {120X3}

4. Injectable {118X4} {119X4} {120X4}

5. NORPLANT@ {118X5} {119X5} {120X5}

6. Condom {118X6} {119X6} {120X6}

7. Diaphragm {118X7} {119X7} {120X7}

8. Spermicide {118X8} {119X8} {120X8}

9. Other: {Il8X9R} {118X9} {119X9} {120X9}

ASK 21. Does the health facility (including the Tick if provided MCH/FP unit) usually provide the following services or counselling? (Read 1-6)

1. Female sterilization (MULA) {121Xl}

2. Vasectomy {12l X2}

3. Natural family planning counselling {12l X3}

4. Exclusive breastfeeding counselling (LAM) {12l X4}

5. Dual methods counselling {12l X5}

6. Emergency contraception {121X6}

Inventory • 37 Screening and diagnostic facilities

ASK 22. Is any laboratory testing for STDs, HIV, or pregnancy offered at this SDP? {122}

1 Yes 2 No (to q.241

ASK 23. Is there a test for (read 1-7) available at A. Tick if test B. Tick if clients or this MCH/FP unit or at this health facility, or available at health specimens are sent are clients' specimens, or the clients facility elsewhere themselves, sent elsewhere?

1. Syphilis {123A 1} {123B1}

2. Gonorrhea {123A2} {123B2}

3. Chlamydia {123A3} {123B3}

4. HIV {123A4} {123B4} 5. Candida {123A5} {123B5} 6. Cervical cancer (pap smear) {123A6} {123B6} 7. Pregnancy {123A7} {123B7}

Immunization services

ASK 24. Does this health facility ASK 25. (If immunization provided) usually provide the following Has the drug for the immunization services? (Read 1- immunization ever been out of 6 and tick if provided) stock at this health facility in the last 6 months? (Tick if yes)

1. BCG {124X1} {125X1 }

2. Polio {124X2} {125X2}

3. DPT {124X3} {125X3}

4. Measles {124X4} {125X4}

5. Hepatitis B {124X5} {125X5}

6. Tetanus for {124X6} {125X6} ANC clients

Inventory • 38 Commodity management

ASK 26. Is there a written OBS 27. (If there is an inventory) inventory for the following Is it up-to-date, legible, and commodities and supplies? complete? (Read 1-4 and tick if yes) (Tick if yes)

1. FP contraceptives {126Xl} {127Xl}

2. Drugs for STD {126X2} {127X2} treatment

3. Vaccines {126X3} {127X3}

4. Other medicines {126X4} {127X4}

ASK 28. Are the following OBS 29. For each commodity, commodities stored by are the storage facilities expiry date? In other words, protected from rain, sun, is there a system of "first adverse temperatures, rats, expiry first out?" and pests? (Read 1-4 and tick if yes) (Read 1-4 and tick if yes)

1. FP contraceptives {128Xl } {129Xl }

2. Drugs for STD {128X2} {129X2} treatment

3. Vaccines {128X3} {129X3}

4. Other medicines {128X4} {129X4}

Inventory· 39 Record-keeping and reporting

ASK 30. How are the clients' record cards maintained at this facility? {130}

1 Kept in clinic 2 = Kept by client (to q.32) 3 No cards (to q.32) 4 Other: {130R}

OBS 31. In what condition is the record-card system? {13l}

1 Well ordered 2 Partially ordered, still usable 3 Disordered, not usable

ASK 32. Is there a common daily activity register for all the MCH-FP services provided by this health facility? {132}

1 Yes for all services 2 Yes for some of the services 3 Separate register for each of the services 4 No daily activity register for any of the services

ASK 33. Are service statistics reports for the following services Tick if sent to a supervisor or higher unit? (Read 1-3) reports sent

1. MCH {133Xl }

2. FP {133X2}

3. STD/HIV/AIDS {133X3}

Inventory' 40 Management and supervision

ASK 34. How many times in the last six months has a supervisor come to this MCH/FP unit for supervisory purposes? {134}

------times

ASK 35. When visiting this facility, what does the supervisor Tick if mentioned do? (Do not read, but probe by asking, "Any other actions?")

1. Observe delivery of different services {135X1 }

2. Observe only service he/she is responsible for {135X2}

3. Inquire about service problems {135X3}

4. Examine the records {135X4}

5. Make suggestions for improvements {135X5}

6. Offer praise for good work {135X6}

7. Other: {135X7R} {135X7}

Service statistics

Compile statistics for the number of clients served in a continuous period of 12 months in any of the last 24 months. In those cases where a continuous 12-month period is not available, use the longest continuous period for which there are statistics, and record the number of months in column C.

OBS 36. How many clients received A. New clients B. Repeat clients C. Based on the following services in the number of months past 12 months? of continuous (99999 = no data available) records

1. Family planning {136A 1} {136B1 } {136C1 }

2. Antenatal services {136A2} {136B2} {136C2}

3. Delivery services {136A3} {136B3} {136C3}

4. Postnatal services {136A4} {136B4} {136C4}

5. HIV/AIDS services {136A5} {136B5} {136C5}

6. STD services {136A6} {136B6} {136C6}

7. Child welfare {136A 7} {136B7} {136C7}

OBS 37. Indicate the calendar month and year of the most recent month reported in the table above.

month {137X1 } year ______{137X2}

Inventory· 41 ASK 38. What is the client A. Consultation fee B. Commodity/ charged for obtaining test/procedure each method or service? (Read 1 - 26)

1. Combined pill {138A 1} {138B 1}

2. Progestin-only pill {138A2} {138B2}

3. IUD {138A3} {138B3}

4. Injectable {138A4} {138B4}

5. NORPLANT® {138A5} {138B5}

6. Condom {138A6} {138B6}

7. Diaphragm {138A7} {138B7}

8. Spermicide {138A8} {138B8}

9. Female sterilization (MULA) {138A9} {138B9}

10. Vasectomy {138A 1O} {138B10}

11. NFP counselling {138A11} {138B11}

12. LAM counselling {138A12} {138B12}

13. Antenatal care {138A 13} {138B 13}

14. Maternity care / {138A14} {138B 14} delivery services

15. Postnatal care {138A15} {138B15}

16. HIV/AIDS counselling / IEC {138A16} {138B 16}

17. HIV/AIDS testing {138A 17} {138B 17}

18. Other STD counselling /IEC {138A 18} {138B 18}

19. Other STD diagnosis {138A 19} {138B19}

20. Other STD treatment {138A20} {138B20}

21. Child immunization {138A21 } {138B21 }

22. Child growth monitoring {138A22} {138B22}

23. Infertility consultation {138A23} {138B23}

24. Oral rehydration therapy {138A24} {138B24}

25. Treatment of incomplete {138A25} {138B25} abortion

26. Nutrition counselling {138A26} {138B26}

Inventory· 42 Inventory: question-by-question 1. What is the official opening time for guide this health facility? This instrument may take as long as the en­ 2. At what time did the first family tire day for one person to fill out. It should planning client arrive today? be started soon after arrival. If the field 3. At what time was the f"lrst family researcher is not a nurse, s/he will need the planning client seen today? assistance of the nurse to inventory the These questions will determine if the equipment and supplies. The process of SDP is actually open and providing ser­ conducting the inventory requires making vices at the official opening time. Try to observations and asking questions of the arrive at the SDP before it is officially staff in charge of FP services at the SDP. The time for it to open. Record the time that abbreviations ASK or OBS on the left side of the first family planning client arrived, the item numbers instruct the field re­ and at what time she began her consul­ searcher whether to ask the question or to tation with a provider. Receiving a observe the situation to obtain the informa­ health talk does not count as being tion sought. Note that since the staff in "seen" by a provider. When entering charge of FP services will be interviewed times, be sure to circle "am" or "pm." with the Staff Interview Instrument, it will be necessary for the various members of the 4. At what time was the last family field research team to coordinate times for planning client seen today? each instrument and to be sensitive not to This question requires that you stay at overwhelm the staff. the SDP until it stops offering services, to be sure that you have identified the Cover page last client of the day. If there was only Before you begin the inventory, complete all one FP client, fill in the time that one the information on the cover page (except client was seen in questions 3 and 4. the questionnaire number, which will be completed at the end of the data collection 5. What is the official closing time for by your Team Leader). This page is similar this health facility? to the cover page on all the other question­ Ask the staff in charge of FP services naires. It is extremely important that the about the official closing time. This codes for health facility, district, and village/ question, with question 4, will show if town are correct. Ask your Team Leader if services are offered during the stated you are not sure. Ask the head of the SDP to hours. identify for you the type of health facility, the type of sector, and the locality. If there is 6. How many days per week are family any confusion, ask your Team Leader. planning services offered at this Write (do not sign) your name in the health facility? box at the bottom of the page. When Ask the staff in charge of FP services the you have completed the inventory, your number of days per week FP services Team Leader will review it and sign below are offered. Parts of days count as full your name. days. That is, if services are offered for

Inventory: question-by-question guide • 43 two hours per day, three days a week, do not tick this box. Turn on a light enter 3. If services are offered for eight switch. If there is no electricity, do not hours one day a week, enter 1. tick this box, even if the staff tell you that it is a power cut on the day of the 7. Is there a sign announcing that FP visit only. Check the toilets to see that services are available? they are actually in working order. If, Signs help clients understand that they based on your own judgment, they are can receive FP services at the SDP. Look dirty and unusable, do not tick this box. for a sign that says FP services are avail­ able at this facility. Sometimes the sign 10. How many (various stafftypes) are is outside near the road, and sometimes assigned to work full time at this it is inside the SDP building. If there are MCH/FP section? several signs, code appropriately. The staffing pattern at an SDP can indi­ cate the level of services that could or 8. Is (several services) usually avail­ should be provided there. Ask the staff able to clients at this MCH/FP unit in charge of FP services how many staff or elsewhere in the health facility? of each type work full time at this MCH/ These questions will help assess the FP section. Do not include positions that range of services that are offered at the are established but not currently filled. SDP. Ask the staff in charge of FP ser­ Include staff only if they provide FP ser­ vices whether each of the services is vices. Staff members provide FP services usually available, and at what part of the if they do one or more of the following facility. "Usually available" means of­ things: fered at least three days per week. If a • counsel clients by giving them infor­ service is available at both this MCH/FP mation about contraceptive methods unit and elsewhere in the facility, tick or refer them to other SDPs for services; both. If it is available only elsewhere in • perform sterilizations; the facility, tick column B, even if there • give injections or insert IUDs or is no standard referral system. NORPLANT®; • prescribe pills; 9. On the day ofthe visit, does the • give clients condoms, foam, or jelly. MCH/FP unit have the following (ba­ sic infrastructure)? 11. How many (various stafftypes) are The basic infrastructure of an SDP af­ on duty today? fects its ability to provide high quality As a follow-up to the previous question, services, as well as clients' satisfaction ask the number of those staff members with services. Tick if the SDP has piped identified in the first column who are on running water, electricity, working toi­ duty today. If a staff member is sup­ lets, and sufficient seating for clients. posed to be on duty, but is out today Check the water: is it actually running? due to illness or other problem, do not Sometimes there is a tap and pipes but count her as "on duty." This information no water. If there is no running water, will assess the SDP's practical, daily ca-

Inventory: question-by-question guide • 44 pacity to deliver services (as compared 15. Are the following conditions present to the formal capacity measured by the in the examination area? previous question). The conditions of the examination room can dramatically affect the quality of 12. Which lEe materials on the follow­ care given as well as clients' satisfaction ing subjects are available in the with the SDP. You will have to. use your MCH/FP unit? judgment regarding auditory and visual lEC materials can be valuable aids to privacy, cleanliness, and adequate light communication, and their presence en­ and water. Here are some guidelines: hances the quality of services. For each • "auditory privacy" means that a con­ item in this question, it is important that versation between a client and a you actually verify that a particular lEC nurse or doctor cannot be understood material is present. To verify, you must by other clients. The other clients actually see it. Look for posters on the might be able to see that a conversa­ walls or doors of the SDP. Ask the staff tion is taking place but they cannot in charge of FP services if they have hear what is being said. If there are flipcharts, brochures, or pamphlets. Tick no clients on the day of the visit and the appropriate box only if you actually you cannot judge the level of privacy, see the materials. If the SDP only has a enter 98 in the box. few brochures or pamphlets-not • "visual privacy" means that other cli­ enough to distribute to clients-still tick ents cannot see the interaction be­ them as available, since they can be tween a client and a doctor or nurse. used during client counseling. Usually this means that there is a sepa­ rate examination room that is private or 13. Was a "health talk" (group lecture or there is an area that has a curtain or discussion with clients) held today? other partition that prevents other cli­ 14. (If yes) Which topics did the "health ents from seeing what is happening. If talk" include? there are no clients on the day of the These questions assess whether clients visit and you cannot judge the level of have access to information on FP and privacy, enter 98 in the box. RH outside of consultations with provid­ • "clean" means that at the start of the ers. Health talks are usually given at the day, fresh linen is used on beds and ex­ very beginning of the day by a nurse/ amination tables and fresh towels are midwife. In order to determine if a provided. It also means that the floors health talk was given, you must arrive at are swept and mopped and there is no the SDP before it opens for business. If visible dust or dirt on the window sills you did not actually see that a health or tables. If you arrived significantly af­ talk was given because you arrived late, ter the start of services, and cannot circle 98. If you actually heard the judge if the linens were clean at the health talk, circle 1, and tick the topics start of the day, enter 98 in the box. listed in question 14 that were included • "adequate light" means a functioning in the talk. electric light or sufficient natural light

InventOly: question-by-question guide • 45 from a window that a nurse or doctor 19. (If method is usually provided) can do an adequate examination. Physically check and tick ifcom­ • "adequate water" means a sufficient modities available today quantity of clean water for washing 20. (Ifmethod is usually provided) Has hands and equipment. The source of there been any stock-out in the last the water might be from pipes or a six months? well in the compound. The purpose of these questions is to find out if the SDP provides a particular 16. Tick ifthe following types of equip­ contraceptive method, and if so, how re­ ment are available and working in liable its contraceptive stocks are. The the MCH/FP unit, and/or in the stocks are particularly important be­ stockroom for MCH/FP services. cause if there are no commodities, an 17. Count the number ofthe following SDP simply cannot offer a method, even types of equipment available and if it is otherwise ready to do so. working in the MCH/FP unit, Ask the staff in charge of FP services and/or in the stockroom for MCH/ which methods are actually provided at FP services. the SDP. Tick the appropriate boxes un­ This is one of the most important sec­ der question 18. Then go to the stock tions. Each item on the list has been room or cabinet and actually check the identified as necessary for FP services, contraceptive supplies. Tick the box under RH service, or infection prevention. The question 19 if there is at least one unex­ presence or absence of any item will pired unit of each type of commodity. Be greatly affect services. Verify the pres­ sure to check the expiration date. If there ence of each item by actually seeing is no expiration date, do not count the and counting all the equipment in both item. (It might seem strange to tick the the clinic and storeroom. If it is not pos­ box if there is only one cycle of pills, for sible to gain access to the storeroom, example, but after much experimentation enter the number seen in the clinic and with the methodology, we have found that note this problem in the margin. It is ex­ counting the number of commodities tremely important to determine whether available at an SDP is extremely time con­ the equipment actually works. For ex­ suming and does not actually produce ample, if a flashlight (torch) is available much more informative data.) If it is not but does not have batteries, then it possible to gain access to the supplies, should not be counted. If a sterilizer is then write 98 in these boxes. available but is not used because it does The information for question 20 can not work, it should not be counted. If a come from two sources. First, ask the piece of equipment is shared with other staff in charge of FP services or the per­ providers, it should still be counted. son in charge of logistics if any contra­ ceptive methods have ever been out of 18. Does the MCH/FP unit usually pro­ stock in the last six months. Second, try vide each ofthe following contra­ to verify whether they have been out of ceptive methods? stock by checking the records, if avail-

Inventory: question-by-question guide • 46 able. If either the staff member or the MCH program. Ask the staff in charge of records indicate a stock-out, tick the col­ FP services whether each immunization umn under question 20. If there is some service is provided. "Usually provided" confusion, enter 98 in these boxes. means at least three days per week.

21. Does the health facility (including the 25. (Ifimmunization provided) Has the MCH/FP unit) usually provide the fol­ drug for the immunization ever lowing services or counseling? been out of stock at this health facil­ Ask the staff in charge of FP services if ity in the last 6 months? each service or counseling is usually The information for this question can provided. "Usually provided" means at come from two sources. First, ask the least three days per week. staff in charge of FP services or the per­ son in charge of logistics if any of the 22. Is anylaboratorytestingfor SlDs, HIV, immunization drugs have ever been out of or pregnancy offered at this SDP? stock in the last six months. Second, try to Diagnostic services for STDs/HIV and verify whether L~ey have been out of pregnancy should be part of a compre­ stock by checking the records, if available. hensive FP/RH service program. Ask the If either the staff member or the records staff in charge of FP services whether the indicate a stock-out, tick the column un­ facility offers testing for STDs/HIV or der question 25. If there is some confu­ pregnancy. If not, skip to question 24. sion, enter 98 in these boxes.

23. Is there a test for (various STDs/ 26. Is there a written inventory for the pregnancy) available at this MCH/FP following commodities and supplies? unit or at this health facility, or are 27. (Ifthere is an inventory) Is it up-to­ clients' specimens, or the clients date, legible, and complete? themselves, sent elsewhere? Ask the staff in charge of FP services or The purpose of this question is to dis­ person in charge of logistics if there is a cover if this sort of testing is available to written inventory for the listed commodi­ clients who visit this SDP, whether or not ties. An "inventory" is a system to keep the testing is performed on-site. Ask the track of the number of commodities re­ staff in charge of FP services whether the ceived and the number dispensed. If so, tests are performed at this health facility, ask to see the inventory and check if it or if the clients are referred elsewhere, or is up-to-date, legible, and complete. If if the specimens are sent off-site for test­ you cannot gain access to the inventory, ing. If the test is not offered at all, leave enter 9 in the column under question 27. both columns blank. 28. Are the following commodities stored 24. Doesthis healthfacility usuallyprovide byexpiry date? In otherwords, is there the following immunization services? a system of"f"11"st expiry f"lrSt out?" Immunization services are another im­ A storage system based on expiration portant component of an integrated FP/ date protects clients from receiving ex-

Inventory: question-by-question guide • 47 pired commodities and allows the SDP records. Use your judgment as to avoid wastage. For each commodity, whether the system is well-ordered, ask the staff in charge of FP services or partially ordered but still usable, person in charge of logistics if the com­ or not usable. modities are stored by expiration date. Verify the answers by asking to see the 32. Is there a common daily activity reg­ system for recording expiration dates ister for all the MCH/FP services and stocking accordingly. provided by this health facility? Daily activity registers are useful for the 29. For each commodity, are the storage SDP manager to monitor the client load facilities protected from rain, sun, and plan for services in the future. Ask adverse temperatures, rats, and if there is a daily activity register for all pests? services. Verify the existing registers by If commodities are exposed to these asking to see them. various threats, then their effectiveness and safety will be compromised. Ask to 33. Are service statistics reports for the see where the commodities are stored following services sent to a supervi­ and determine whether the storage is sor or higher unit? adequate, meaning no exposure to rain It is important that service statistics are or sun, protected from rats and pests, sent to a higher unit because this allows and not subject to excessive heat. Note central monitoring and coordination of that for some vaccines, protection from services, which can improve their qual­ adverse temperatures would involve re­ ity. For each service, ask the staff in frigeration. Usually, commodities are charge of FP services if monthly statisti­ stored in a separate room or in a steel cal reports of client load are sent to a or wood cabinet. supervisor or higher unit.

30. How are the clients' record cards 34. How many times in the last six maintained at this facility? months has a supervisor come to 31. In what condition is the record-card this MCH/FP unit for supervisory system? purposes? These questions address the issue of People generally tend to perform better continuity of care. Well-kept client if they know that someone is interested records allow providers to build on the and concerned about their work. Super­ care previously received and establish at visory visits should serve this function least a partial medical history for each and thereby improve the quality of ser­ client. Ask the staff in charge of FP ser­ vices. Ask the staff in charge of FP ser­ vices about the client record card sys­ vices for the number of supervisory tem: are the cards maintained at the visits that were made in the last six SDP, or are they kept by clients? If they months for the purpose of reviewing are kept at the SDP, ask to see the services. It is important that you deter-

Inventory: question-by-question guide • 48 mine that the visits were made for su­ statistics are not available. Enter the pervisory purposes, not to provide ser­ number of months you are using (l to vices or any other function. If there is a 12) in column C. supervisor's visit record book, ask to Once the table is complete, enter in check it. question 37 the calendar month and year of the most recent month used in 35. When visiting this facility, what the table. This gives an idea of the does the supervisor do? recency of the data. If there has been a supervisory visit in the last six months, ask the staff in 38. What is the client charged for ob­ charge of FP services about the taining each method or service? supervisor's actions. (Consultation fee, commodity/test/ procedure) 36. How many clients received the The accessibility of a method or service following services in the past 12 is affected by its cost. By gathering in­ months? formation on client fees, we can better 37. Indicate the calendar month and understand the financial barriers to ser­ year ofthe most recent month re­ vice. Ask the staff in charge of FP ser­ ported in the table above. vices about the fees new clients pay for The purpose of these questions is to as­ each method or service. Remember that sess the client load, by service, at each these are fees that the client actually SDP. This can help illustrate the connec­ pays, not the cost to the SDP of pro­ tion between quality of services and ser­ viding a method or service. Ask for vice utilization. the fees charged to an average new Ask to see the SDP's service statistics client, not one who has complications records. For each service, check to see if with the method or service or an un­ the SDP has 12 consecutive months of usual medical history. Be sure to di­ service statistics in the last 24 months. You vide the fees into those for the can use any 12 months in the last 24­ consultation (column A) and for the month period, as long as the 12 months commodity, test, or procedure (column are consecutive. If there are gaps and it is B). If the method/service has fees for impossible to obtain 12 consecutive both a commodity and a procedure, months, then take the most recent set of such as IUD insertion, enter in column months for which statistics are available. B the complete fee to the client for all In some cases, only two or three con­ commodities, tests, and procedures secutive months may be possible. combined. For some methods/services, In columns A and B, record the total such as LAM counseling or nutrition number of new clients and repeat cli­ counseling, there will be no fees for ents for each service. If you have any commodity/test/procedure. If the problems reading the statistics, make a method or service is not offered at the note in the margins. Code "99999" if the SDP, leave both columns blank.

Inventory: question-by-question guide • 49 Observation guide

This data collection instrument is designed provider interaction takes place and you know to help you record what happens when a where to record the information. The introduc­ provider, such as a nurse/midwife or doctor, tory section of the Observation: question-by­ counsels and examines a family planning cli­ question guide (page 59) as well as the ent. This observation is one of the most impor­ section on "Tips for conducting a good ob­ tant parts of a Situation Analysis study. It is servation" (page 24) present more informa­ also probably the most difficult to complete tion on how to complete this instrument. and requires good listening and observing The codes presented in brackets {} in this skills. Often when observing the interaction instrument are suggested variable names for between the client and the provider you will each question or tick mark. These names are have to make notes and then record the an­ referred to in the analysis plan (beginning swer to some of the items later. You should try on page 162). Keep in mind, however, that to become very familiar with the observation they would not appear on the actual ques­ guide and even memorize parts of it so that tionnaires used by researchers in the field. you know what to look for when the client See following pages for instrument.

Observation guide • 50 Country Name Situation Analysis Study Questionnaire number: {OlD}

Observation Guide for Interaction Between Family Planning Clients and Service Providers

INSTRUCTIONS TO OBSERVER: Obtain the consent of both client and provider before proceeding to observe the interaction between them. Make sure that the provider knows that you are not there to evaluate her/him and that you are not an "expert" who can be consulted during the session. When observing, be as discreet as possible: try to sit so that you are behind the client but not directly in view of the provider, and make notes quickly. For each question, circle the response that most appropriately represents your observation of what happened during the interaction. As discussed in the training, you may witness behavior that poses a serious risk to the client's health. Please keep in mind the guidelines for when to intervene in the consultation on behalf of the client's welfare.

Health facility visited (name): {HFNAME}

Health facility code: {HFCODE}

District (name): {DISTNAME}

District code: {DISTCODE}

Village/town (name): {TOWNNAME}

Village/town code: {TOWNCODE}

Study client number: {CLlID}

Client's location/ward: {CLILOC}

Study staff number: {STAFFID}

Date of visit: Day _ Month _ year _ {DATE}

Name of observer: _

Signature of team leader: _

Observation guide • 51 Type of health facility: {TYPE} 1 Referral Hospital 2 District Hospital 3 Primary Hospital 4 Rural Health Center 5 = Maternity 6 Health Post 7 Pharmacy 8 CBD 9 Other

Type of sector: {SECT} 1 Government 2 FPA 3 Mission 4 Private 5 Other

Locality: {LOC} 1 Rural 2 = Urban

Designation of staff member: {DESIG} 1 Doctor 2 Nurse 3 Nurse-midwife 4 CBD 5 6 7 Two or more providers: Specify: _ {DESIG 1} {DESIG2} {DESIG3}

Time observation began: {TIMEBEG}

Main purpose of visit as first indicated by client: {PURPOSE}

New clients: 1 New FP acceptor 2 "Restart" FP acceptor

Revisit clients: 3 Resupply or repeat visit (without problems) 4 Resupply or repeat visit (problem with method, wanted to change method, or wanted to discontinue FP)

Observation guide • 52 I New clients I Revisit clients Greeting and Assessing the Client

1. Did the provider greet the client in a friendly 1 = Yes manner? {01} 2 = No 2. Did the provider ask about {02X1 } 1 = Whether the client wanted more children in the or did the client spontaneously future mention any of these subjects? {02X2} 2 = Age of youngest child {02X3} 3 = Whether the client is breastfeeding (Circle all that apply.) (Tick if client breastfeeding during observation:_ ) {02X4} 4 = Client's marital status {02X3BR} {02X5} 5 = If client has had more than one sexual partner in past year {02X6} 6 = If client has any questions {02X7} 7 = If client has concerns about her own health {02X8} 8 = If client has concerns about using any method {02X9} 9= If client has any concerns about STDs or HIV/AIDS {02X10} 10= If client had previous symptoms/signs/treatment suggestive of STDs {02X11 } 11 = If client has discussed family planning with husband/partner {02X77} 77 = None of these subjects 3. Did any provider ask about {03X1} 1 = Any medical/family history or did the client spontaneously {03X2} 2 = Date of LMP mention any of these subjects? {03X3} 3 = Abnormal vaginal bleeding {03X4} 4 = Abnormal vaginal discharge (Circle all that apply.) {03X5} 5 = Genital itching {03X6} 6 = Lower abdominal pain {03X77} 77 = None of these subjects 4. During the consultation, {04X1} 1 = Assess weight (check card) did any provider take or perform {04X2} 2 = Take BP (check card) any of these actions? {04X3} 3 = Perform/refer for pregnancy test {04X4} 4 = Perform general physical exam (Circle all that apply.) {04X5} 5 = Perform/request/refer for a blood test {04X6} 6 = Perform a breast exam {04X7} 7 = Perform/request/refer for a pap smear (see Medical Procedures Performed) {04X8} 8 = Perform a syndromic analysis for STDs (04X77} 77 = None of these actions

Observation guide' 53 I New clients I Revisit clients Discussion of Family Planning [ I 5. Did the provider ask about or did the client 1 = Yes spontaneously mention any previous 2= No method use? {O5} 6. Before coming to the health facility, what {O6} contraceptive method was the client using? Method code: 7. Did the provider ask about or did the client 1 = Yes spontaneously mention wanting to change 2= No methods or stop using? {O7} 8. Did the provider ask about or did the client 1 = Yes spontaneously mention any problems with 2= No her current method? {O8} 9. (If client had problems {09X1 } 1 = Counselled client with her method) about problem Did the provider take {09X2} 2= Gave medical any of these actions? treatment {09X3} 3= Suggested/agreed (Circle all that apply.) that client change method {09X4} 4= Referred client elsewhere for treatment {09X77} 77 = No actions 10. Did the provider ask or did the client 1 = Yes spontaneously mention a specific {O10} 2= No preference for a contraceptive method? 11 . (If yes) Which method? {011 } Method code: 12. Please note the methods that the provider Method codes: mentioned or discussed during the 1 2 3 4 5 consultation. 6 7 8 9 (Circle all that apply.) 10 11 12 13 {012X1} to {012X13} 13. (If the client accepts a method {013X1} 1 = How to use method or switches to a new method} {013X2} 2= Advantages For the new method accepted, {013X3} 3= Disadvantages did the provider talk about {013X4} 4= Medical side effects (e.g. bleeding, nausea, etc.) any of these issues? {013X5} 5= What to do if client has problem with method {013X6} 6= Possibility of switching (Circle all that apply.) {013X7} 7= Ability of method to prevent STDs/HIV {013X77} 77 = None of these issues 14. (If the client chose LAM) {014X1} 1 = Client must not have had menses since delivery Did the provider mention {014X2} 2= Infant must be less than six months old any of these points? {014X3} 3= Client must be fully/nearly fully breastfeeding (Circle all that apply.) {014X77} 77 = None of these points 15. Did the provider overemphasize one method 1 = Yes in particular? {O15) 2= No

Observation guide • 54 New clients I Revisit clients 16. Which IEC materials, if any, {016X1} 1 = Flipchart were used during the {016X2} 2= Brochure/pamphlets consultation? {016X3} 3= Contraceptive samples {016X4} 4= Posters (Circle all that apply.) {016X5} 5= Other: {016X5R} {016X77} 77 = None

Discussion of STDs and Other Health Issues

17. During the consultation, did the provider 1 = Yes explicitly mention that the condom protects 2= No against STDs/HIV/AIDS? {O17} 18. Did the provider indicate to the client that 1= Yes she might have an STD? {O18} 2= No

19. (If yes) What did the {019X1} 1 = Request laboratory tests provider do? {019X2} 2= Treat {019X3} 3= Refer elsewhere (Circle all that apply.) {019X4} 4= Provide counselling {019X5} 5= Other: {019X5R} {019X77} 77 = No actions taken

20. What other health issues {020X1} 1 = HIV/AIDS were mentioned at any time {020X2} 2= Other STDs during the consultation? {020X3} 3= Child immunization {020X4} 4= Child growth monitoring (Circle all that apply.) {020X5} 5= Infertility {020X6} 6= Oral rehydration therapy {020X7} 7= Abortion {020X8} 8= Nutrition {020X9} 9= Curative services - client {020X10} 10= Curative services - child {020X11} 11 = Breastfeeding {020X12} 12 = Sexual relations {020X13} 13 = Social/economic factors {020X14} 14= Pregnancy testing {020X15} 15 = Other: {020X15R} (Q20X77} 77 = None of these issues

Observation guide • 55 I New clients I Revisit clients Family Planning Decision, Supply, and Follow-up

21. Did the client decide to use a contraceptive 1 = Yes method? {021 } 2= No 22. (If not) What is the main reason client 1 = Came for info only did not choose a method? {O22} 2= Changed mind 3= Pregnancy suspected (Circle one.) 4= Medical contraindications (No more questions this section.) 5= Breastfeeding 6= Other health reasons 7= Method not available 8= No obvious reason 9= Other 23. What decision did the client make about 1 = Continue same family planning? {O23} method 2= Stop (Circle one.) 3= Switch 24. (If stopping or switching) What is the main 1 = Wants pregnancy reason for stop or switch? {O24} 2= Unwanted side effects (Circle one.) 3= Inconvenient supply 4= Husband/partner (If stopping, no more questions this doesn't like method section.) 5= Switch spacing to permanent method 6= Other 8= Reason not clear 25. What new method did the client finally decide to use/switch to? {O25} Method code: 26. Was the method that the client decided to 1 = Yes use the same method she initially preferred? 2= No (See q.10 and 11) {O26} 3= No preference expressed 27. (If not) Why did the client decide not 1 = Client changed her mind after hearing about methods to use the method she initially 2= Provider felt there were medical contraindications preferred? {O27} 3= Provider felt method inappropriate due to age, marital status, etc. (Circle one.) 4= Pregnancy suspected 5= Method out of stock 6= Other: {027R} 7= No obvious reason 28. Was the method that the client decided to 1 = Yes use supplied to the client today? {02B} 2= No I 29. (If not) Why was the client not 1 = Referred to another place for method supplied with her method today? 2= Client to return with menses {O29} 3= Method out of stock 4= Client to return for TLlIUD/NORPLANT® procedure (Circle one.) 5= Other: {029R}

Observation guide • 56 New clients I Revisit clients 30. (If not) Was an alternative method 1 = Yes provided to the client to use while 2= No waiting to recieve her method of choice? {O30} 31. (If yes) Which method was given for the interim? {031 } Method code: 32. (If the client chose pills, condoms, spermicides) How many units of the units method was the client given? {O32} Pill units = cycles, Condom units = pieces, (999 = Not known) Spermicide units = tubes (describe if otherwise) 33. Was the client told when to return for 1 = Yes resupply or follow-up? {O33} 2= No 34. (If yes) Did the provider give a written 1 = Yes reminder to the client of when to 2= No return? {O34} 35. Was the client told where to go for resupply 1 = Yes or follow-up? {O35} 2= No 36. (If yes) Where? {036Xl } 1 = This health facility {036X2} 2= Another health facility (Circle all that apply.) {036X3} 3= Pharmacy / shop /chemist / private doctor {036X4} 4= CBD/FWE {036X5} 5= Other

Observation guide • 57 I New clients I Revisit clients Medical Procedures Performed I I 37. If a pelvic exam was performed, {037X1 } 1 = Inform the client what would happen before the did the provider: exam? (Circle all that apply.) {037X2} 2= Wash hands before the exam? {037X3} 3= Visually inspect external genitalia? {037X4} 4= Take a pap smear/specimen? {037X5} 5= Perform a digital/bimanual examination? {037X6} 6= Wash hands after the exam? {037X7} 7= Inform the client about the result after the exam? {037X77} 77 = None of these actions 38. If a speculum examination {038X1} 1 = Use a clean speculum? was performed, did the provider: {038X2} 2= Use gloves? (see gloves question) (Circle all that apply.) {038X77} 77 = None of these actions 39. If an IUD was inserted, {039X1} 1 = Sound the uterus? did the provider: {039X2} 2= Handle the IUD with aseptic procedures? {039X3} 3= Use gloves? (see gloves question) (Circle all that apply.) {039X4} 4= Offer emotional support? {039X77} 77 = None of these actions 40. If an injectable was given, {040X1} 1 = Disinfect injection site? did the provider: {040X2} 2= Use a sterile needle? {040X3} 3= Massage injection site? (Circle all that apply.) {040X77} 77 = None of these actions 41. If NORPlANT@ was inserted, {041X1} 1 = Wash client's arm with soap and water? did the provider: {041X2} 2= Use gloves? (see gloves question) {041X3} 3= Apply an antiseptic solution to insertion site? (Circle all that apply.) {041X4} 4= Place client's arm on a sterile cloth? {041X77} 77 = None of these actions 42. If gloves were used, {O42} 1 = Sterile were the gloves: 2= Clean but not sterile 3= Not clean (Circle one.) 98 = Unable to determine level of cleanliness

Time observation finished: {TIMEEND} Duration of interaction: ---- {DUR}

Staple an exit interview to this questionnaire, follow the client out of the consultation, introduce her, and give both questionnaires to the interviewer.

Method codes: 1 Combined pill (or unspecified) 8 Spermicide 2 Progestin-only pill 9 Female sterilization (MULA) 3 IUD 10 Vasectomy 4 Injectable 11 NFP 5 NORPLANT@ 12 LAM 6 Condom 13 Other 7 Diaphragm

Observation guide • 58 Observation:question-by-question the interaction. There is no set sequence, as guide in the ordering of questions in an interview. Take note of the instructions to observer on You need to become familiar with all of the the first page of the instrument. All of the in­ elements that you are expected to observe structions are important. You should be able and their location on the data collection to fill out most of the material on the first form, so you can quickly find an item and two pages before the observation begins. If code it as the interaction unfolds. you are not sure about any of the identifying Several general headings provide some codes, ask your Team Leader. Write (do not organization of the questions and will help sign) your name in the box at the bottom of you quickly find the appropriate place to the second page. When you have completed code an item of interest. The headings in­ the observation, your Team Leader will re­ clude: Greeting andAssessing the Client, view it and sign below your name. which covers the medical and social infor­ Also near the bottom of the second page, mation that the provider may wish to know you will find "Main purpose of visit as first in order to properly assess the client for indicated by client:" Please keep in mind family planning; Discussion ofFamily Plan­ that we have different expectations of a pro­ ning, which includes specific information vider who is giving service to a "new client" about FP methods, the client's history of FP and a "revisit client." Both of these types of practice, client preferences, etc.; Discussion clients may be classified further as is indi­ ofSills and otherHealth Issues, and Family cated by the codes. For new clients, stay Planning Decision, Supply, and Follow-up. alert to any questions or mention of whether During training and practice, you must be­ the client has ever used a contraceptive be­ come familiar with the location of each item fore or not. If she has never used a FP of interest in the observation. method ever, she is a "new" FP acceptor. If Note that this form has two columns on she has used one or more methods in the the righthand side-one for new clients and past, but is not currently using a method, one for revisit clients. Most questions apply she is a "restart." If the client is currently to both new and revisit clients, but some ap­ using a method (just before this visit) then ply only to one type of client. When a ques­ she is a "revisit client." Note that revisit cli­ tion is only relevant to a new client, the ents can come for a variety of reasons. revisit client column will be shaded out, and There is considerable overlap between visa versa. When a question is relevant to "problem with method," "wanted to change both new and revisit clients, the separation method," and "wanted to discontinue FP," between the columns disappears. because all are generally associated with cli­ For several questions, instead of writing ents who are having problems. Thus we do out individual family planning methods, you not attempt to distinguish between these will be required to use a code for each various clients. method. A list of the codes for methods is As you proceed through the instrument, on the last page of the observation (page keep in mind that an observation is different 58). This list of codes is used wherever con­ from an interview in that we do not know traceptive methods are to be recorded in the the order that items of interest will arise in observation, and with time it will probably

Observation: question-by-question guide • 59 become easier for you to use the codes than Greeting and Assessing the Client to write out individual methods. 1. Did the provider greet the client in After the observation is over, follow the a friendly manner? client out of the room and politely ask if she Refer to your training for a culturally ap­ is willing to be interviewed about her expe­ propriate definition. Remember to rience. If she agrees, then introduce her to pay attention to tone of voice, facial the social science interviewer. expressions, gestures, eye contact, Reviewing the instrument at the conclu­ all of which may be used to decide sion of the observation is an extremely im­ whether the greeting was friendly portant step. Look over the entire instrument or not. and consider whether each of the items of interest took place. You should be especially 2. Did the provider ask about or did alert to code 77, indicating that none of the client spontaneously mention these subjects were discussed/observed. You any ofthese subjects? will also need to skim down the "new" or We are interested in whether the infor­ "revisit" column on the right side of the mation is available to the provider. page to check that the observation and re­ We do not distinguish whether the cording are complete, and that you have al­ client spontaneously mentioned an item, ways coded the material in the correct or answered a question about an item. column. Note that the client might not mention The observation form is rather dense; a breastfeeding, and would not normally considerable amount of information is to be be asked about whether she is recorded on a few pages. The reason this in­ breastfeeding, if she is breastfeeding strument is dense, and uses certain "short­ during the service delivery. There is a cuts" (method codes, and two columns for special place to tick if the client is new and revisit clients) is to reduce the breastfeeding during service delivery. amount of paper that needs to be shuffled Remember these items can only be to find a particular item. A previous, and sig­ noted when they happen or at the nificantly longer, version of the observation conclusion of the observation during led to some errors when observers could your review. not quickly find the items they required. Although we generally do not want to dis­ 3. Did any provider ask about or turb the provider-client interaction, and do­ did the client spontaneously men­ ing so may invalidate the research objectives tion any of these subjects? of the visit, remember the guidance pro­ 4. During the consultation, did any vided in training on what to do if you wit­ provider take or perform any of ness provider behavior that poses a serious these actions? risk to the client's health. Please keep in We are interested in whether you ob­ mind the guidelines for when to intervene in serve any of these actions during the in­ the consultation on behalf of the client's teraction. Question 3 deals with health welfare. (See the "Ethical issues" section for issues discussed with the client, and more information, page 17.) question 4 addresses physical measure-

Observation: question-by-question guide • 60 ments taken from the client. Note the use 8. Did the provider ask about or of code 77 in both questions, indicating did the client spontaneously men­ that none of these items were discussed tion any problems with her or performed. This can only be coded in current method? your final review, after the consultation 9. (If client had problems with her is over. method) Did the provider take any It is possible that some of these ac­ ofthese actions? tions-such as taking blood pressure­ These questions should only be an­ may have been taken at another place in swered for revisit clients. Note that the facility by another provider, who question 9 is indented, and starts with marked the client record with the infor­ "(If client had problems with her mation. If possible, check the client method)." Proceed to question 9 record for such actions in addition to only if the answer to question 8 is making the observations of the specific "yes." Note the code 77 on question 9, provider client interaction you are to be used if the client had problems observing. but the provider took no action.

Discussion ofFamily Planning 10. Did the provider ask or did the 5. Did the provider ask about or did client spontaneously mention a the client spontaneously mention specific preference for a contracep­ any previous method use? tive method? This information is sought for new 11. (Ifyes) Which method? clients only. Research indicates that many clients have a contraceptive in mind when they 6. Before coming to the health come to the clinic and that clients tend facility, what contraceptive method to be happier, and continue using their was the client using? method longer when they obtain the Not~ the client would only be using a contraceptive they originally had in contraceptive method before coming to mind. Of course, the provider may dis­ the facility if she is a revisit client. cover medical contraindications or other The answer space for "new clients" is reasons why the client may not obtain shaded out. Use the method codes the method she had in mind, but we are on page 58. interested in knowing if she had a pref­ erence in any case. We are particularly 7. Did the provider ask about or did interested in this information prior to the client spontaneously mention the delivery of education/counseling wanting to change methods or stop when method-specific information using? is provided. Note this implies the client was already Note the skip pattern-answer using a method. Therefore this question question 11 only if question 10 is should only be answered for revisit "yes." Use the codes for methods on clients. page 58.

Observation: question-by-question guide • 61 12. Please note the methods that the negative aspects of others, or being very provider mentioned or discussed enthusiastic about one method and unen­ during the consultation. thusiastic about others. We are looking for Note that the methods do not have to instances of providers demonstrating bi­ be mentioned all at once. Whenever the ases in favor of a particular method. A provider mentions or discusses a specific recommendation from the pro­ method, code accordingly. Any mention vider based on a medical condition or of a method whatsoever receives full particular circumstances that come out credit. Use the codes for methods on in counseling mayor may not be page 58. "overemphasis."

13. (If the client accepts a method or 16. Which lEe materials, if any, were switches to a new method) For the used during the consultation? new method accepted, did the pro­ Some providers use visual materials to vider talk about any ofthese issues? help demonstrate the points they make. This question records the content of in­ These materials may include posters, formation given to the client about the brochures, flip charts, or the contracep­ method she accepted. Clients who are tive samples themselves. It is common, given more information about their for example, for providers to hold a method, particularly concerning side ef- package of pills and show the client . fects, tend to continue contracepting how to start taking them and in what or­ longer. Note the 77 code if none of der. Often, this use of IEC materials these issues were discussed. communicates information more effec­ tively to clients than language alone. 14. (If the client chose LAM) Did the The inventory instrument takes stock provider mention any ofthese of the IEC materials that are available at points? each SDP. This information will be used LAM stands for Lactational Amenorrhea in the data analysis to determine Method. It is unlikely that the provider whether IEC materials were available to will use this term; be alert to a descrip­ each provider. If the provider you are tion of exclusive breastfeeding as a FP observing does not use IEC materials method and code accordingly. Use the because there are none at the SDP, code 77 code only ifthe client chose LAM but this as a 77. The fact that the materials the provider did not mention any of the were not available to her will be dis­ important dimensions of LAM. cerned later.

15. Did the provider overemphasize one Du~~ron~S7VsandO~~ method in particular? Health Issues Overemphasis can be indicated by vari­ 17. During the consultation, did the ous provider behaviors-only discussing provider explicitly mention that the one FP method, mentioning only the condom protects against STDs/HIV/ positive aspects of one method and only AIDS?

Observation: question-by-question guide • 62 Condoms are used both for FP and for Because the rest of this section deals prevention of diseases. We wish to with the supply of methods and follow­ know if the disease protection function up arrangements, none of the questions of condoms was mentioned explicitly, apply to clients who stop using FP. If even if the client is not using condoms you have answered question 22, you currently, or is not accepting condoms need not answer any more questions in as her method today. this section.

18. Did the provider indicate to the cli­ 23. What decision did the client make ent that she might have an STD? about family planning? 19. (If'yes) What did the provider do? 24. (If stopping or switching) What is The provider may indicate to the client the main reason for stop or switch? that she might have an STD directly or These questions are for revisit clients indirectly. Be aware that she might not only. If the client is stopping or specifically mention the term "STD", but switching, try to decide on the main might use "vaginal infection" or some reason for that choice and code accord­ other term. ingly. If the provider suspects an STD, Because the rest of this section deals question 19 determines what action, if with the supply of methods and follow­ any, the provider took for the client. If up arrangements, none of the questions no actions were taken, circle 77. apply to clients who stop using FP. If you have answered question 24 as 20. What other health issues were men­ "stop," then you need not answer any tioned at any time during the con­ more questions in this section. sultation? The purpose of this question is to mea­ 25. What new method did the client fi­ sure the integration of services at the SDP. nally decide to use/switch to? This addresses the method that the cli­ ent finally decided on, not to be con­ Family Planning Decision, Supply, fused with the method she preferred andFollow-up initially, the method she may have been 21. Did the client decide to use a contra­ using previously, or the method she may ceptive method? have been supplied with today as a tem­ Note this question for new clients only, porary method. Use the method codes since revisit clients are already using a on page 58. method. Revisit clients who are switching methods are addressed in question 23. 26. Was the method that the client de­ cided to use the same method she 22. (If' not) What is the main reason cli­ initially preferred? ent did not choose a method? 27. (If not) Why did the client decide If the new client decides not to use a not to use the method she initially method, then record her reason here. preferred?

Observation: question-by-question guide • 63 If a client has a preference for a method 33. Was the client told when to return but does not receive it, she may be dis­ for resupply or follow-up? couraged from using family planning. 34. (If yes) Did the provider give a writ­ Check questions 10 and 11 to see if her ten reminder to the client ofwhen final decision matches her preference. to return? 35. Was the client told where to go for 28. Was the method that the client de­ resupply or follow-up? cided to use supplied to the client 36. (If yes) Where? today? All of these follow-up and supply ques­ 29. (If not) Why was the client not sup­ tions relate to the ability of the client to plied with her method today? continue with her method once she has In some cases, the client may decide to begun using it. Similar questions are use a method, but not actually asked of the client in the exit interview, physically receive that method today. so we can measure whether this infor­ For this question, "supplied" means re­ mation is being absorbed by clients. ceiving pills or condoms/spermicides, getting an injection, having and IUD or Medical Procedures Performed NORPLANT® inserted, undergoing a tu­ Take special note of which procedures were bal ligation, etc. If the client chose LAM performed on clients, and answer only the or natural family planning, which do not relevant questions. If the client did not re­ require any supplies or procedures, ceive a procedure, do not circle any re­ circle "yes." sponses. If the client received a procedure but none of the listed actions were followed, 30. (If not) Was an alternative method circle 77. Please do not circle 77 to mean provided to the client to use while "procedure did not take place." waiting to receive her method of choice? 37. (If a pelvic exam was performed) 31. (Ifyes) Which method was given for Did the provider: the interim? This is only for clients who received a These questions should only be an­ pelvic examination. If the provider used swered if the response to question 28 was a speculum, be sure to answer question "no." Use the method codes on page 58. 38 as well.

32. (Ifthe client chose pills, condoms, 38. (If a speculum examination was per­ or spermicides) How many units of formed) Did the provider: the method was the client given? This is only for clients with whom a Note the description of the units used speculum was used during her pelvic for each of these methods: pills = examination. A "clean speculum" is de­ monthly cycles; condoms = number of fined as either sterile or "high level individual condom pieces; and clean" (disinfected but not necessarily spermicides = number of tubes of foam sterilized). Sometimes it is difficult to tell tablets, etc. whether the speculum is clean or not.

Observation: question-by-question guide • 64 Make your best estimate. If gloves were 42. (If gloves were used) Were the used, answer question 42. gloves: This is only for situations in which the 39. (If an IUD was inserted) Did the provider used gloves during a part or all provider: of the procedures. "Clean" means high This is only for dients who received an level clean or a new pair of disposable IUD. Recall your training regarding gloves. "Sterile" means unwrapped from aseptic procedures and the definition of the autoclave. Make your best estimate, emotional support. If gloves were used, but if it is not clear, circle 98. answer question 42. Time observation finished 40. (If an injectable was given) Did the Duration ofinteraction provider: Note the time the observation was finished, This is only for clients who were given and check the time the observation began an injectable contraceptive. (on page 52) to find the duration of the interaction. 41. (If NORPLANT® was inserted) Did the provider: This is only for clients who were given NORPLANT®. If gloves were used, an­ swer question 42.

Observation: question-by-question guide • 65 Family planning client exit interview

This instrument gathers information from The codes presented in brackets {} in this family planning clients about the services instrument are suggested variable names for they have just received. This information is each question or tick mark. These names are used in assessing the quality of care that cli­ referred to in the analysis plan (beginning ents receive from SDPs, which can be com­ on page 162). Keep in mind, however, that pared to the quality of care that is presented they would not appear on the actual ques­ to clients. This tells us whether information tionnaires used by researchers in the field. is communicated effectively, how clients feel See instrument on following pages. about the services, and how much clients understood the process of selecting a family planning method.

Family planning client exit interview • 66 Country Name Situation Analysis Study Questionnaire number: _ {FID}

Exit Interview for Family Planning Clients

INSTRUCTIONS TO INTERVIEWER: Copy the information from the front of the observation guide to this page of the exit interview. Read the greeting on the next page to the client, and continue only if she gives her consent. For each item in the rest of the interview, circle the response or describe as appropriate.

Health facility visited (name): {HFNAME}

Health facility code: {HFCODE}

District (name): {DISTNAME}

District code: {DISTCODE}

Village/town (name): {TOWNNAME}

Village/town code: {TOWNCODE}

Study client number: {CLlID}

Client's location/ward: {CLILOC}

Study staff number: {STAFFID}

Date of visit: Day _ Month _ Year _ {DATE}

Name of observer: _

Signature of team leader: _

Family planning client exit interview • 67 Type of health facility: {TYPE} 1 Referral Hospital 2 District Hospital 3 Primary Hospital 4 Rural Health Center 5 Maternity 6 Health Post 7 Pharmacy 8 CBD 9 Other

Type of sector: {SECT} 1 Government 2 FPA 3 Mission 4 Private 5 Other

Locality: {LOC} 1 Rural 2 = Urban

Main purpose of visit as first indicated by client: {PURPOSE}

New clients: 1 New FP acceptor 2 "Restart" FP acceptor

Revisit clients: 3 Resupply or repeat visit (without problems) 4 Resupply or repeat visit {problem with method, wanted to change method, or wanted to discontinue FPI

Family planning client exit interview • 68 For all clients

Read greeting:

Hello. We would like to improve the services provided by the facility and would be interested to find out about your experience today. I would like to ask you some questions about the visit you have just had with the (health facility staff) and would be very grateful if you could spend some time answering these questions. I will not write down your name, and everything you tell me will be kept strictly confidential. Also, you are not obliged to answer any question you don/t want to, and you may withdraw from the interview at any time. May I continue?

(If the client agrees to continue, ask if she has any questions. Respond to questions as appropriate, then ask q.1.

If the client does not agree to continue/thank her and go to the next interview.)

1. Overall, would you say you were satisfied with your visit to the facility today, or were you dissatisfied with your visit today? {F1}

1 Satisfied (to q.3) 2 Dissatisfied 3 Other: (to q.3)

2. Why were you dissatisfied with your visit today? {F2}

: 3. In addition to family planning, did you receive any other health services from the service provider? {F3} 1 = Yes 2 No (to q.5)

Family planning client exit interview· 69 4. Now I would like to ask you about all the other services you received today. Did you receive any of the following Tick if received services? (Read 1 - 16)

1. Antenatal care {F4X1}

2. Maternity carel delivery services {F4X2}

3. Postnatal care {F4X3}

4. HIV/AIDS counselling {F4X4}

5. HIV/AIDS testing {F4X5}

6. Other STD counselling {F4X6}

7. Other STD diagnosis {F4X7}

8. Other STD treatment {F4X8}

9. Child immunization {F4X9}

10. Child growth monitoring {F4X10} , 11. Oral rehydration therapy {F4X11 }

12. Treatment of incomplete abortion {F4X12} I

13. Nutrition counselling {F4X13} .

14. Curative services - client {F4X14}

15. Curative services - child {~4X15}

16. Other: {F4X16R} {F4X16}

5. Do you feel that you received the information and services that you wanted today? {F5}

1 Yes 2 = No 3 = Partially 98 = Don't know

6. Do you feel that your FP consultation with the clinical staff was too short, too long, or about the right amount of time? {F6}

1 Too short 2 Too long 3 About right 98 = Don't know

7. During this visit, did you have any concerns about family planning or other health issues that you wanted to discuss with the provider? {F7}

1 = Yes 2 No (to q.9l

Family planning client exit interview· 70 8. (If yes) Did the provider listen to your concerns to your satisfaction? {F8}

1 Yes 2 No

9. During this visit, did you have any questions you wanted to ask? {F9}

1 Yes 2 No (to q. 12)

I 10. (If yes) Did the provider let you ask the questions? {F10}

1 = Yes 2 No (to q.12)

11. (If yes) Did the provider respond to your questions to your satisfaction? {F11}

1 Yes 2 No

12. During this visit, did the provider conduct any health examinations or procedures? {F12} 1 Yes 2 = No (toq.15)

13. (If yes) Did the provider explain the examinations or procedures before they were performed? {F13} 1 Yes 2 No

14. Did the provider explain the results of the health examinations or procedures? {F14}

1 = Yes 2 No

15. In your opinion, did you have enough privacy during your consultation with the service provider? {F15} 1 = Yes 2 No

16. During the consultation, did you feel that the provider was easy to understand when explaining things to you, or did you feel that the provider was difficult to understand? {F16}

1 = Easy to understand 2 = Difficult to understand 98 = Don't know

17. If you could suggest one improvement to the services provided, what would it be? {F17}

Family planning client exit interview· 71 18. During this visit, were you given or did you take any brochure or educational material to bring home? {F18} 1 = Yes 2 = No (to q.20) 98 = Don't know (to q.20)

19. (If yes) What was the subject(s) of that material? (Do not read list, but probe by asking, "Any other subjects?") Tick if mentioned

1. Family planning {F19Xl} I

2. Antenatal I Postnatal care {F19X2}

3. Delivery services {F19X3}

4. HIV/AIDS {F19X4}

5. Other STDs {F19X5}

6. Child welfare {F19X6} 7. Nutrition {F19X7} I 8. Other: {F19X8R} {F19X8} l 98. Don't know {F19X98}

20. Did you attend a group talk(s) at the facility today? {F20}

1 = Yes 2 = No (to q.22) 98 = Don't know (to q.22)

Family planning client exit interview • 72 21. (If yes) What topics were covered in the group talk(s)? (Do not read list, but probe by asking, "Any other topics?" ) Tick if mentioned

1. Family planning {F21Xl}

2. Antenatal care {F21 X2}

3. Maternity carel delivery services {F21 X3}

4. Postnatal care {F21 X4}

5. HIV/AIDS {F21 X5}

6. Other STDs {F21 X6}

7. Child immunization {F21 X7}

8. Child growth monitoring {F21 X8}

9. Infertility {F21 X9}

10. Oral rehydration therapy {F21Xl0}

11 . Treatment of incomplete abortion {F21Xll}

12. Nutrition counselling {F21X12}

13. Curative services - clients {F21X13}

14. Curative services - children {F21X14}

15. Breastfeeding {F21X15}

16. Other: {F21 X16R} {F21 X16}

98. Don't know {F21 X98}

22. Did any service provider tell you when to come back for another visit? {F22}

1 = Yes 2 = No 98 = Don't know

23. Are the hours this facility is open convenient for you? {F23}

1 = Yes (to q.25) 2 = No 98 = Don't know (to q.25)

24. (If no) What time would be most convenient to you? (Circle one.) {F24} 1 Earlier in morning 2 Over lunch hour 3 Afternoon 4 Evening I night 5 Weekends I holidays 6 Other: _ {F24R} 98 = Don't know

Family planning client exit interview· 73 25. Have you ever been turned away from this facility during official working hours? {F25}

1 Yes 2 No 3 No previous experience with facility 98 = Don't know

26. About how long did you have to wait between the time you first arrived at this facility and the time you began receiving the services that you came for? {F26}

_____ minutes 98 = Don't know (If no waiting time, to q.28)

27. Do you feel that the wait between the time you first arrived at this facility and the time you began receiving the services you came for was reasonable or too long? {F27}

= Reasonable 2 = Too long 98 = Don't know

28. How long did it take you to come here today? {F28}

_____ minutes 98 = Don't know

29. What was the main means of transport that you used to get here? (Circle one.) {F29}

1 Walked 2 Donkey cart 3 Bus / combi 4 Bicycle 5 Private car 6 Other: _ {F29R}

Family planning client exit interview' 74 30. As far as you know, what types of services other than family planning are usually provided at this facility? (Do not read, but probe by Tick all mentioned asking, "Any other services?")

1. Antenatal care {F30Xl }

2. Maternity care/delivery services {F30X2}

3. Postnatal care {F30X3}

4. HIV/AI DS counselling/IEC {F30X4}

5. HIV/AIDS testing {F30X5}

6. Other STD counselling/IEC {F30X6}

7. Other STD diagnosis {F30X7}

8. Other STD treatment {F30X8}

9. Child immunization {F30X9}

10. Child growth monitoring {F30X1O}

11 .Infertility consultation {F30Xll }

12. Oral rehydration therapy {F30X12}

13. Treatment of incomplete abortion {F30X13}

14. Nutrition counselling {F30X14}

15. Curative services - client {F30X15}

16. Curative services - child {F30X16}

17. Other: {F30X17R} {F30X17}

98. Don't know any services {F30X98}

31. Apart from this facility, is there any other place near your home where you can go for family planning? {F31} 1 = Yes 2 = No (to q.34) 98 = Don't know (to q.34)

Family planning client exit interview • 75 32. (If yes) What type of facility is it? (Circle one. If more than one facility, choose closest to home.) {F32} 1 CBD 2 Health post 3 Health center 4 Hospital 5 Other {F32R} 98 = Don't know

33. What would you say is the main reason you did not go there for family planning? (Do not read list. Probe for the main reason and circle one.) {F33}

1 Inconvenient opening times 2 Takes too long to get there 3 Poor quality service 4 Fewer services available 5 Want to be anonymous 6 Have other reasons to come here (e.g. MCH services) 7 More expensive there 8 Prefer provider here 9 Other: {F33R} 98 = Don't know

34. Now I would like to ask you about the cost of travel and services that you have recieved from this clinic. How much did you pay for your consultation? {F34}

(local currency units) 98 = Don't know

35. How much did you pay for medicines? {F35}

_____ (local currency units) 98 = Don't know

36. How much did you pay for other items such as cotton, gloves, antiseptic, or syringes? {F36}

_____ (local currency units) 98 = Don't know

37. How much did you pay for registration card/membership? {F37}

_____ (local currency units) 98 = Don't know

38. How much did you pay for travel? {F38}

_____ (local currency units) 98 = Don't know

39. How much did you pay for any other services or fees? {F39}

_____ (local currency units) 98 Don't know

Family planning client exit interview • 76 40. Overall, do you feel that the total cost of obtaining services is much too expensive, a little too expensive, or acceptable to you? {F40}

1 = Much too expensive 2 A little too expensive 3 Acceptable 98 = Don't know

41. (See client's main purpose of visit on page 2, then read this question.)

I understand that your main purpose for coming to the health facility today was (insert purpose from page 2). Is this correct? {F41}

(If correct, circle the same response that appears on page 2, and skip to the question indicated. If not correct, ask for the correct purpose of the client's visit, circle the correct response below, and skip to the question indicated)

1 New FP acceptor 2 "Restart" FP acceptor 3 Resupply or repeat visit (to q.55) 4 Problem with method, wanted to change method, or wanted to discontinue FP (to q.59) 5 Other (to q.101)

Family planning client exit interview, 77 For new acceptors

42. Just to make sure, I understand that you were not using a contraceptive method when you came to the facility today. Is it correct that you were not using a method? {F42}

1 = Was not using 2 = Was using (return to q.41 )

43. Have you ever used any contraceptive method in the past? {F43}

1 = Yes 2 No (to q.45)

(If yes) Which method{s) have you ever used? 44. , (Do not read methods but probe by asking, "Have you ever used any Tick if mentioned i other methods?") , 1. Combined pill (or unspecified) {F44X1 }

2. Progestin-only pill {F44X2} , 3. IUD {F44X3}

4. Injectable {F44X4} , {F44X5} 5. NORPLANT® !

{F44X6} 6. Condom I

7. Diaphragm {F44X7}

8. Spermicide {F44X8}

9. Female sterilization (MULA) {F44X9}

10. Vasectomy {F44X10} ! 11 . NFP {F44X11 } i {F44X12} I 12. LAM I i 13. Other: {F44X13R} {F44X13} i 98. Don't know {F44X98} I i

45. Did you get a contraceptive method during this visit? {F45}

1 Yes (to q.47) 2 = No

Family planning client exit interview • 78 46. (If no) What is the main reason you did not obtain a contraceptive method today? (Circle one.) {F46} 1 = Came for information only (to q.1 01) 2 Changed my mind (to q.1 01) 3 Pregnancy suspected (to q. 101 ) 4 = Contraindications for selected method (to q.1 01) 5 Continue breastfeeding (to q.1 01) 6 = Other health reason (to q. 101) 7 Method not available (to q. 101 ) 8 Other: (to q. 101 ) {F46R} 98 = Don't know (to q.1 01)

47. Which method(s) did you accept today? (Do not read methods but probe by asking, "Did you accept any Tick if mentioned other methods?")

1. Combined pill (or unspecified) {F47X1 }

2. Progestin-only pill {F47X2}

3. IUD {F47X3}

4. Injectable {F47X4} 5. NORPLANT@ {F47X5}

6. Condom {F47X6}

7. Diaphragm {F47X7}

8. Spermicide {F47X8}

9. Female sterilization (MULA) {F47X9}

10. Vasectomy {F47X10}

11. NFP {F47X11}

12. LAM {F47X12}

13. Other: {F47X13R} {F47X13}

98. Don't know {F47X98}

Family planning client exit interview • 79 48. Did the provider mention any other methods to you? 1 = Yes 2 = No 98 = Don't know

49. Did the provider tell you that you can switch methods if you are not happy with this method? {F49} 1 = Yes 2 = No 98 = Don't know

50. Did the provider tell you another source of supply or follow-up for your method? {F50} 1 = Yes 2 = No 98 = Don't know

51 . Is there some method other than the one you accepted today that you would have preferred to use? {F51} 1 = Yes 2 = No (to q.54) 98 = Don't know (to q.54)

52. (If yes) Which method would you have preferred to use most? (Circle one.) {F52}

1. Combined pill (or unspecified) 2. Progestin-only pill 3. IUD 4. Injectable 5. NORPLANT@ 6. Condom 7. Diaphragm 8. Spermicide 9. Female sterilization (MULA) 10. Vasectomy 11. NFP 12. LAM 13. Other: {F52R} 98. Don't know

Family planning client exit interview • 80 53. Why are you not going to use this preferred method? (Do not read list, but probe by asking"Any other reasons?") Tick if mentioned

1. Provider said not appropriate {F53X1}

2. Method not offered at facility {F53X2}

3. Trained provider absent {F53X3}

4. Method temporarily out of stock {F53X4}

5. Other: {F53X5R} {F53X5}

98. Don't know {F53X98}

54. (Circle the most effective method accepted by the client, from q. 47.) I would now like to ask you about how to use (read method). {F54}

1 Combined pill (to q.72) 2 Progestin-only pill (to q.72) 3 IUD (to q.81) 4 = Injectable (to q.89) 5 = NORPLANT@ (to q.1 01) 6 = Condom (to q.97) 7 Diaphragm (to q.1 01) 8 Spermicide (to q.97) 9 Female sterilization (to q.1 01) 10 Vasectomy (to q.1 01) 11 NFP (to q.101) 12 LAM (to q.101) 13 Other: (to q. 101) {F54R}

Family planning client exit interview· 81 For revisit clients (without problems)

55. Just to make sure, I understand that you were using a contraceptive method when you came to the facility today. Is it correct that you were using a method? {F55}

1 Yes, was using 2 No, was not using (return to q.41)

56. Which method(s) were you using? (Do not read methods but probe by asking, "Any other methods?") Tick if mentioned

1. Combined pill (or unspecified) {F56Xl }

2. Progestin-only pill {F56X2} :

3. IUD {F56X3}

4. Injectable {F56X4}

5. NORPLANT@ {F56X5}

6. Condom {F56X6}

7. Diaphragm {F56X7}

8. Spermicide {F56X8}

9. Female sterilization (MULA) {F56X9}

10. Vasectomy {F56Xl0}

11 . NFP {F56Xl1}

12. LAM {F56X12}

13. Other: {F56X13R} {F56X13}

98. Don't know {F563X98}

57. Are you planning to continue using this method? {F57} 1 = Yes 2 = No (to q.62) 98 = Don't know (to q.1 01)

58. (Circle the most effective method used by the client, from q. 56 or 60.) I would now like to ask you about how to use (read method). {F58}

1 Combined pill (to q.72) 8 = Spermicide (to q.97) 2 Progestin-only pill (to q.72) 9 = Female sterilization (to q.1 01) 3 IUD (to q.81) 10 Vasectomy (to q.1 01) 4 = Injectable (to q.89) 11 NFP (to q.101) 5 NORPLANT@ (to q.1 01) 12 LAM (toq.101) 6 Condom (to q.97) 13 Other (to q.1 01) 7 Diaphragm (to q.1 01)

Family planning client exit interview • 82 For revisit clients (problem with method, wanted to change or stop)

59. Just to make sure, I understand that you were using a contraceptive method when you came to the facility today. Is it correct that you were using a method? {F59}

1 Yes, was using 2 No, was not using (return to q.41)

60. Which method(s) were you using? (Do not read methods but probe by asking, "Any other methods?") Tick if mentioned

1. Combined pill (or unspecified) {F60X1 }

2. Progestin-only pill {F60X2}

3. IUD {F60X3}

4. Injectable {F60X4}

5. NORPLANT® {F60X5}

6. Condom {F60X6}

7. Diaphragm {F60X7}

8. Spermicide {F60X8}

9. Female sterilization (MULA) {F60X9}

10. Vasectomy {F60X10}

11. NFP {F60X11 }

12. LAM {F60X12}

13. Other: {F60X13R} {F60X13}

98. Don't know {F60X98}

61. Is it correct that you had a problem, wanted to change methods or wanted to stop family planning? {F61} 1 Yes 2 No (return to q.57)

62. What was the main problem you had, or the main reason you wanted to change or stop? (Circle one.) {F62} 1 Medical side effects 2 Husband/partner did not like method (to q.65) 3 Pressure from others (to q.65) 4 Fear of infertility (to q.65) 5 = Wanted pregnancy (to q.65) 6 = Didn't like method (to q.65) 7 = Method unavailable / difficult to obtain (to q.65) 8 Other: (to q.65) {F62R} 98 = Don't know (to q.65)

Family planning client exit interview, 83 63. (If had medical side effects) When you first decided to use this method, were you told that this problem might happen? {F63}

1 = Yes 2 = No (to q.65) 98 = Don't know (to q.65)

64. (If yes) Were you told what to do about the problem? {F64}

1 = Yes 2 = No 98 = Don't know

65. After this consultation today, do you feel that you are getting appropriate assistance for your particular needs? {F65} 1 Yes 2 = No 3 = Partially 98 = Don't know

66. What are you now going to do about family planning? (Circle one.) {F66}

1 Change to new method 2 Continue with same method (to q. 71) 3 Stop using any method (to q.1 01) 98 = Don't know (to q.71) 67. (If changing method) What method(s) will you now be using? (Do not read methods but probe by asking, "Any other methods?") Tick if mentioned

1. Combined pill (or unspecified) {F67X1 }

2. Progestin-only pill {F67X2}

3. IUD {F67X3}

4. Injectable {F67X4}

5. NORPLANT@ {F67X5}

6. Condom {F67X6}

7. Diaphragm {F67X7}

8. Spermicide {F67X8}

9. Female sterilization (MULA) {F67X9}

10. Vasectomy {F67X10}

11 . NFP {F67X11 }

12. LAM {F67X12}

13. Other: {F67X13R} {F67X13}

98. Don't know {F67X98}

Family planning client exit interview • 84 68. Did the provider mention any other methods to you? {F68} 1 = Yes 2 = No 98 = Don't know

69. Did the provider tell you that you can switch methods if you are not happy with this method? {F69} 1 = Yes 2 = No 98 = Don't know

70. Did the provider tell you another source of supply or follow-up for your method? {F70} 1 = Yes 2 = No 98 = Don't know

71. (Circle the most effective method now used by the client, from q.60 or q.67.) I would now like to ask you about how to use (read method). {F71}

1 Combined pill (to q.72) 2 Progestin-only pill (to q.72) 3 IUD (to q.81) 4 = Injectable (to q.89) 5 NORPLANT@ (to q.1 01) 6 = Condom (to q.97) 7 Diaphragm (to q.1 01) 8 Spermicide (to q.97) 9 Female sterilization (to q.1 01) 10 Vasectomy (to q.101) 11 NFP (to q.101) 12 LAM (toq.101) 13 Other: _ (to q.101) {F71R}

Family planning client exit interview • 85 For pill users

72. When a woman first starts using the pill, at what time in the menstrual cycle do you think she should start taking it? {F72}

1 = Within 1st - 5th day of menstrual period 2 = Any other answer 98 = Don't know

73. How often do you think a woman should take her contraceptive pills? {F73}

1 = One every day 2 = Any other answer 98 = Don't know

74. If a woman forgets to take the pill for one day, what do you think she should do? {F74}

1 = Take the forgotten one immediately 2 = Any other answer 98 = Don't know

75. Does the pill protect a woman against STDs/HIV? {F75} 1 Yes 2 = Partially 3 = No 98 = Don't know

76. As far as you know, what problems, if any, maya woman experience when taking the pill? Tick all mentioned (Do not read list, but probe by asking, .. Any other problems?")

1. Nausea {F76X1 }

2. Mild headaches {F76X2}

3. Spotting / bleeding {F76X3}

4. Weight gain / loss {F76X4}

5. Cancer {F76X5}

6. Infertility {F76X6}

7. Other: {F76X7R} {F76X7}

77. No problems mentioned {F76X77}

98. Don't know {F76X98}

Family planning client exit interview • 86 77. Apart from the regular return or resupply visit, for what problems, if any, do you think a woman taking pills should come back to the Tick if mentioned facility? (Do not read list, but probe by asking, "Any other problems?")

1. Severe chest pain, shortage of breath {F77X1}

2. Severe headache {F77X2}

3. Vision loss or blurring {F77X3}

4. Severe abdominal pain {F77X4}

5. Severe leg pain {F77X5}

6. Late period {F77X6}

7. Other: {F77X7R} {F77X7}

77. No problems mentioned {F77X77}

98. Don't know {F77X98}

78. Did the service provider give you a supply of pills today? {F78}

1 = Yes (to q.80) 2 = No

79. (If no) Where will you go to get your pills? (Circle one.) {F79}

1 = Within another section of this health facility today 2 = Return to this health facility at another time 3 Another health facility 4 Pharmacy I shop I chemist I private doctor 5 CSD 6 = Other: {F79R} 98 = Don't know

80. Toq.101

Family planning client exit interview • 87 For IUD users

81. Did your visit to the facility today involve an IUD insertion, removal, or routine check-up? {F81}

1 Insertion today 2 Removal 3 Routine check-up, previously inserted

82. As far as you know, how can a woman check to be sure that the IUD is in place? (Circle all that apply.)

1 Checking the threads regularly {F82X1 } 2 Go to the health facility {F82X2} 3 Any other answer {F82X3} 98 = Don't know {F82X98}

83. As far as you know, what problems, if any, maya woman experience with an IUD? Tick all mentioned (Do not read list, but probe by asking, .. Any other problems?")

1. Abdominal cramps {F83X1 }

2. Heavy bleeding {F83X2}

3. Spotting between menstrual periods {F83X3}

4. Backache / "waist-ache" {F83X4}

5. Infection (PID) / lower abdominal pain {F83X5}

6. Infertility {F83X6}

7. Increased discharge {F83X7}

8. Other: {F83X8R} {F83X8}

77. No problems mentioned {F83X77}

98. Don't know {F83X98}

84. When do you think a woman should come back for the first check-up after an IUD insertion? (Circle one.) {F84} 1 After one month 2 After three months 3 After one year 4 Any other time 5 No need to come back 98 = Don't know

Family planning client exit interview • 88 85. Apart from the regular check-up visits, for what problems, if any, do you think a woman with an IUD should come back to the facility? Tick all mentioned (Do not read list, but probe by asking, "Any other problems?")

1. Heavy discharge {F85Xl}

2. Abnormal spotting or bleeding {F85X2}

3. Expulsion or cannot feel threads {F85X3}

4. Lower abdominal pain {F85X4}

5. Severe cramps {F85X5}

6. Pain during intercourse {F85X6}

7. Back ache {F85X7}

8. Late period {F85X8}

9. Not feeling well {F85X9}

10. Other: {F85Xl0R} {F85Xl0}

77. No problems mentioned {F85X77}

98. Don't know {F85X98}

86. How many years do you think a woman can keep using an IUD once it has been inserted? {F86}

years 98 = Don't know

87. Does the IUD protect a woman against STDs/HIV? {F87} 1 Yes 2 = Partially 3 = No 98 = Don't know

88. To q.101

Family planning client exit interview • 89 For injectable users

89. Did you receive a contraceptive injection today? {F89}

1 Yes (to q.911 2 No

90. (If no) Where will you go to get your injection? (Circle one.) {F90}

1 Within another section of this health facility today 2 Return to this health facility at another time 3 Another health facility 4 Pharmacy I shop I chemist I private doctor 5 CBD 6 Other: {F90R} 98 = Don't know

91. Which type of injection did (will) you get? (Circle one.) {F91}

1 = Depo Provera 2 = Noristerat 98 = Don't know

92. How often do you think you should get this injection? (Circle one.) {F92}

1 Every month 2 Every two months 3 Every three months 4 Any other interval 98 = Don't know

93. As far as you know, what problems, if any, do you think a woman may experience after having an injection? Tick all mentioned (Do not read list, but probe by asking, "Any other problems?")

1. Mild headaches {F93X1 }

2. Nausea {F93X2}

3. Irregular bleeding I spotting {F93X3}

4. Weight gain {F93X4}

5. Infertility {F93X5}

6. Amenorrhea (absence of period) {F93X6}

7. Other: {F93X7R} {F93X7}

77. No problems mentioned {F93X77}

98. Don't know {F93X98}

Family planning client exit interview • 90 94. Apart from the regular return visit, for what problems, if any, do you think a woman receiving injections should come back to the facility? Tick all mentioned (Do not read list, but probe by asking, "Any other problems?")

1. Headaches (severe, persistent) {F94X1}

2. Heavy bleeding {F94X2}

3. Severe chest pain, shortage of breath {F94X3}

4. Severe lower abdominal pain {F94X4}

5. Severe leg pain {F94X5}

6. Vision loss or blurring {F94X6}

7. Frequent urination {F94X7}

8. Late period {F94X8}

9. Other: {F94X9} {F94X9}

77. No problems mentioned {F94X77}

98. Don't know {F94X98}

95. Does an injection protect a woman against STDs/HIV? {F95} 1 Yes 2 = Partially 3 = No 98 = Don't know

96. Toq.101

Family planning client exit interview • 91 For condom and spermicide users

97. Do condoms/spermicides protect a woman against STDs/HIV? {F97} 1 Yes 2 = Partially 3 = No 98 = Don't know

98. Did you receive a supply of condoms and/or spermicides (cream, foam, jelly) today? {F98}

1 Yes (to q.1 00) 2 No

99. (If no) Where will you go to get your condoms and/or spermicides (cream, foam, jelly)? (Circle one.) {F99}

1 Within another section of this health facility today (to q.1 01) 2 Return to this health facility at another time (to q.1 01) 3 Another health facility (to q. 101 ) 4 Pharmacy / shop / chemist / private doctor (to q.1 01) 5 CSD (to q.101) 6 Other: (to q. 101 ) {F99R} 98 = Don't know (to q.1 01)

100. After you have finished this supply of condoms and/or spermicides, where will you go to get more supplies? (Circle all that apply.) {F100}

1 This health facility 2 = Another health facility 3 Pharmacy / shop / chemist / private doctor 4 CSD 5 = Other: _ {F100R} 98 = Don't know

Family planning client exit interview • 92 For all clients

101. Now, I would like to ask you a few questions about yourself. Are you currently breastfeeding? {F1 01} 1 = Yes 2 = No (to q.103)

102. (If yes) Are you breastfeeding exclusively, nearly exclusively, or supplemented regularly with food and/or liquids? {F102} 1 Breastfeeding exclusively 2 Nearly exclusively 3 Supplemented regularly with food and/or liquids 98 = Interviewer unable to determine extent of supplementation

103. How old are you? {F103} years 98 = Don't know

104. What is your current marital status? (Probe for exact status.) {F104}

1 Married / monogamous (to q.1 06) 2 Married / polygamous (to q.1 06) 3 = Cohabiting (to q.1 06) 4 = Single, never married 5 Divorced / separated / widowed

105. (If not married) Do you have a regular partner? {F105}

1 Yes 2 No (to q.1 08)

106. Have you ever discussed family planning with your husband or regular partner? {F106}

1 = Yes 2 = No 98 = Don't know

107. Does your husband or regular partner know that you use or that you are planning to use family planning? {F107} 1 = Yes 2 = No 98 = Don't know

108. How many living children of your own do you have? {F10B}

children (If none, to q. 110)

109. What is the age of your youngest child? {F109}

months 98 Don't know

Family planning client exit interview • 93 110. Would you like to have any (more) children? (Circle one.) {Fll0}

1 = Yes 2 = No (to q.112) 3 = Depends on husband (to q.112) 4 = Depends on God (to q.112) 5 = Not sure / undecided (to q. 11 2)

111. (If yes) When would you like (a) (the next) child? (Circle one.) {Flll}

1 = Less than one year 2 = One year 3 = Between one and two years 4 = Two years 5 = More than two years 6 = Any other response 98 = Don't know

112. Can you read and understand a letter or a newspaper easily, with difficulty, or not at all? {Fl12}

1 = Easily 2 = With difficulty 3 = Not at all

113. Which languages can you read and understand? Tick if mentioned (Do not read list, but probe by asking, "Any other languages?")

1. English/French {Fl13X1}

2. Local dialect {Fl13X2}

3. Other: {Fl13X3R} {Fl13X3}

4. Other: {Fl13X4R} {Fl13X4}

5. Other: {Fl13X5R} {Fl13X5}

114. What is the highest level of school you attended? (Circle one.) {Fl14}

1 = Did not attend formal school 2 = Lower primary 3 == Upper primary 4 == Lower secondary 5 == Upper secondary 6 == Post-secondary

11 5. What is your religion? (Circle one.) {Fl15} 1 == Protestant 2 == Catholic 3 == Muslim 4 == African Spiritual 5 = None 6 = Other: {Fl15R}

Family planning client exit interview' 94 116. To end with, I would like to ask you some questions about other reproductive health issues. I would like to remind you that the information you provide will remain strictly confidential, and that you do not have to answer any question you do not want to. Sometimes a woman can become pregnant when she is not ready to be. In the past, have you ever been pregnant at a time when you were not ready for the pregnancy? {F116}

1 = Yes 2 = No (to q.118) 98 = Don't know / no response (to q.118)

117. (If yes) What did you do the last time this happened to you? (Circle one.) {Fll7}

1 Nothing, continued with the pregnancy 2 Attempted to stop pregnancy but did not succeed, gave birth 3 Attempted to stop pregnancy and succeeded 4 Other: {F117R} 98 = Don't know / no response

118. As far as you know, are there any diseases that can be transmitted through sexual intercourse? {F118} 1 = Yes 2 = No (toq.120) 98 = Don't know (to q.1 20)

119. From what you've heard or read, what are some common signs and symptoms of sexually transmitted diseases? (Do not read list, but Tick all mentioned probe by asking, "Any other signs or symptoms?")

1. Abnormal vaginal discharge {Fl19X1}

2. Abnormal vaginal bleeding {F119X2}

3. Genital itching {Fl19X3}

4. Lesions / sores {F119X4}

5. Lower abdominal pain {Fl19X5}

6. Pain during intercourse {F119X6}

7. Painful urination {F119X7}

8. Abnormal growth in genital area (warts) {F119X8}

9. Urethral discharge {Fl19X9}

10. Loss of weight {F119Xl0}

11 . Diarrhea of long duration {Fl19X11}

12. Other: {Fl19X12R} {Fl19X12}

98. Don't know {Fl19X98}

Family planning client exit interview· 95 120. Have you ever heard of HIV or AIDS, or are you not sure? {F120}

1 = Yes 2 = No (to q.122) 98 = Not sure (to q.1 22)

121. As far as you know, what are the ways to get HIV/AIDS? (Do not read list but probe by asking, "Any other ways?") Tick all mentioned

1. Sexual intercourse {F121 X1}

2. Blood transfusion {F121X2}

3. Sharing items like razor blades or needles {F121 X3}

4. Mother to baby {F121X4}

5. Other: {F121 X5R} {F121X5}

98. Don't know {F121 X98}

122. Do you know of any ways you can protect yourself from sexually transmitted diseases including HIV/AIDS? {F122} 1 Yes 2 No (to q. 124)

123. (If yes) What are these ways of protecting yourself? (Do not read list, Tick all mentioned but probe by asking, "Any other ways?")

1. Stay faithful to your one spouse/partner {F123X1}

2. Encourage spouse/partner to remain faithful {F123X2}

3. Use condoms {F123X3}

4. Avoid sharing needles, razors, etc. {F123X4}

5. Other: {F123X5R} {F123X5}

124. How many sexual partners have you had in the past 12 months? {F124}

partners (If none, to closing)

125. Did you have sex with any new partner(s) in the past 12 months? {F125}

1 = Yes 2 = No (to closing) 98 = Don't know (to closing)

Family planning client exit interview • 96 126. (If yes) Did you use a condom the first time you had sex with your most recent new partner? {F126} 1 = Yes 2 = No 98 = Don't know/can't recall

Read closing:

Thank you very much for answering these questions.

Family planning client exit interview • 97 Family planning client exit perience. Usually, the clients who have had interview: question-by-question the experience, such as an IUD insertion, guide will be subject to some questions that other The client has just finished receiving FP ser- clients will not answer. These filter questions vices. Most likely a nurse on the field re­ always include a "skip pattern" that skips search team has completed observing the these questions for those clients who did services she received and has now brought not have the experience. Pay careful atten­ the client to you. Be sensitive to the fact that tion to all skip patterns. At the conclusion of the client may have traveled far, waited a long the interview, quickly review your coded re­ time for service, and may have been through sponses for completeness and correctness an ordeal. However, she may agree to an in­ and ensure that you followed the correct terview with a sensitive and interested person. skips. If possible, correct any problems (See the section "Tips for conducting a good while the client is still available. interview" for more information, page 23.) Lead the client to a preselected private For all clients place, away from clinic staff and other cli­ 1. Overall, would you say you were sat­ ents, and read the greeting. This greeting is isfied with your visit to the facility extremely important because it ensures that today, or were you dissatisfied with the client has given her "informed consent" to your visit today? participate in the study. Ask if the client has Clients are frequently reluctant to ex­ any questions about the study. If necessary, press any overall dissatisfaction because you may provide some simple encouragement they wish to be courteous. However, cli­ such as, "Your participation will be greatly ap­ ents tend to be more expressive of dis­ preciated," but in all cases respect the client's satisfaction with more specific wishes if she does not want to be interviewed. questions. Questions 5 through 17 of Ifshe does not agree to participate, thank her this interview will give the client more and move on to the next client. opportunity to specifically critique the You should be able to fill out the informa­ services. tion on the first two pages before the inter­ view begins. If you are not sure about any 2. Why were you dissatisfied with your of the codes, ask your Team Leader. Write visit today? (do not sign) your name in the box at the We are very interested in reasons for bottom of the page. Wilen you have com­ dissatisfaction. Do not rush. You may pleted the interview, your Team Leader will encourage the client to talk further review it and sign below your name. about any dissatisfaction she mentions For the rest of the interview, follow instruc­ with a simple probe. If appropriate, use tions for recording the client's responses by probes like "Can you tell me any more circling a precoded response, ticking a box, about why you feel that way?" or writing a response as instructed. Some questions are filters, which means that they 3. In addition to family planning, did divide clients who have had a certain expe­ you receive any other health ser­ rience from those who have not had that ex- vices from the service provider?

Family planning client exit interview: question-by-question guide • 98 4. Now I would like to ask you about "Concerns" is a broad term. Concerns all the other services you received include but are not limited to worries or today. Did you receive any ofthe fol­ rumors of health risks, side effects, how lowing services? to maintain privacy, partner reactions, These questions address the integration etc. If the client reports that she did of other services with family planning. If have concerns, ask question 8. clients report in question 3 that they re­ ceived other services, ask question 4 9. During this visit, did you have any (see the skip pattern). In question 4, questions you wanted to ask? read each of the services and carefully 10. (Ifyes) Did the provider let you ask place a tick (check mark) in the right the questions? column on the appropriate line of each 11. (Ifyes) Did the provider respond to service received. Remember, a blank your questions to your satisfaction? line in the column (no tick) means the Whether clients feel free to ask ques­ client did not receive that service today. tions and whether they are responded to satisfactorily is a strong indicator of 5. Do you feel that you received the in­ quality in interpersonal relations, and formation and services that you also probably affect a client's continuity wanted today? of use. These three questions address Clients come to a facility in order to ob­ the issue of whether the client felt tain particular information and services. comfortable asking for the information The purpose of this question is to find she needed. out if the client obtained the information "Questions" can be on any subject, and services she desired. such as how a method works or where to buy condoms. Questions can also in­ 6. Do you feel that your FP consulta­ clude "concerns," as defined above. tion with the clinical staff was too Many dimensions may be considered short, too long, or about the right by the client in answering question 11: amount of time? for example, the completeness, correct­ Later, this information can be compared ness, or style the provider used in her to the actual length of the consultation responses. Give no assistance in (from the observation) to discover the answering this question, because only length of time that clients are most com­ the client can determine her own fortable with. satisfaction with the responses to her questions. 7. During this visit, did you have any concerns about family planning 12. During this visit, did the provider or other health issues that you conduct any health examinations or wanted to discuss with the procedures? provider? 13. (Ifyes) Did the provider explain the 8. (Ifyes) Did the provider listen to examinations or procedures before your concerns to your satisfaction? they were performed?

Family planning client exit interview: question-by-question guide • 99 14. Did the provider explain the results 17. Ifyou could suggest one improve­ of the health examinations or ment to the services provided, what procedures? would it be? "Health examinations" include head-to­ This important question allows the cli­ toe exams, breast exams, pelvic exams, ent to mention something that bothered and examinations on any other part of her about the experience, without being the body. "Procedures" include taking critical. Probe with supportive com­ blood pressure or temperature, inserting ments such as: "Anything at all you an IUD, giving an injection, etc. would like to suggest is fine." The idea behind these questions is that if clients are aware of examinations 18. During this visit, were you given or and procedures, they will be more at did you take any brochure or educa­ ease during their visit. An explanation of tional material to bring home? the examination or procedure involves 19. (Ifyes) What was the subject(s) of telling the client what the provider is that material? about to do, why she is doing it, and No distinction is made between bro­ what the client can expect to feel. Ex­ chures, pamphlets, fliers, or any other plaining the results of the examination educational material. Try to find out the or procedure involves telling the subject matter of the brochure or educa­ client if the nurse came to any conclu­ tional material given to the client. Do sions or diagnosis based on the exami­ not read the list, but probe by asking nation. If a diagnosis is not immediately "Are there any other subjects?" available, as with a Pap smear, then ex­ plaining the results would include tell­ 20. Did you attend a group talk(s) at the ing the client that her smear will be facility today? tested and she will be contacted later The "group talk" is sometimes called a about the results. "health talk." It is usually conducted by a nurse, and may include many subjects. 15. In your opinion, did you have It is frequently in the lecture format, but enough privacy during your consul­ when done well, may include questions, tation with the service provider? display of samples, or other AV aides. This is the client's opinion, however she "Attend" and "hear" have similar determines it. meanings in this question.

16. During the consultation, did you 21. (Ifyes) What topics were covered in feel that the provider was easy to the group talk(s)? understand when explaining Ask this question only if the client at­ things to you, or did you feel that tended a group talk. We are interested in the provider was difficult to under­ the information that the client remembers stand? during the health talk, so do not prompt This is the client's opinion, however she her by reading the subject list. Also note determines it. the appropriate probe, "Any other subjects?"

Family planning client exit interview: question-by-question guide • 100 22. Did any service provider tell you the client to estimate the time she when to come back for another visit? waited if she does not have a watch This information is also collected in the and/or did not keep track of the time. observation, so this question can test Reserve "don't know" for clients who whether clients who are given follow-up are unable to estimate, even when re­ dates are aware of them. quested to do so.

23. Are the hours this facility is open 27. Do you feel that the wait between convenient for you? the time you first arrived at this fa­ 24. (If no) What time would be most cility and the time you began receiv­ convenient to you? ing the services you came for was Opening hours of services can be a large reasonable or too long? barrier to clients and these questions get This is the client's opinion about overall at the convenience of the clinic hours. waiting time experienced before she Even in contexts in which clinic hours are started to receive the services she came set by the Ministry of Health or other for. Do not consider the start of registra­ central authority, information from these tion procedures as the services she questions can be very useful for getting came for. those policies changed if necessary. 28. How long did it take you to come 25. Have you ever been turned away here today? from this facility during official We are enquiring about the client's working hours? travel time from her home, because "Turned away" means refused service, travel time can sometimes pose a large or told to come back at another time. barrier to services. If the client was com­ Note that this is about the client's his­ ing from work or relative's house, count tory with the facility (ever), rather than the time from there. Encourage the about today's visit. Also, this involves client to estimate the approximate time being turned away due to overcrowding in minutes. or other unspecified reason. If the client came once, saw a provider, and was 29. What was the main means told to return with her menses, this does oftransport that you used to not count as "turned away" for this get here? question. The client may have used two or three or more forms of transportation-walk­ 26. About how long did you have to ing and minibus would be a common wait between the time you first ar­ combination. When the client used two rived at this facility and the time or more means of transport, encourage you began receiving the services her to decide what she considers her that you came for? main means. Any criteria she uses for The purpose of this question is to deter­ deciding-time, distance, cost, etc.- mine the client waiting time. Encourage is fine.

Family planning client exit intelView: question-by-question guide • 101 30. As far as you know, what types of 34. Now I would like to ask you about services other than family planning the cost of travel and services that are usually provided at this facility? you have received from this clinic. This question addresses clients' aware­ How much did you pay for your ness of other services, which will later consultation? be compared to the actual services 35. How much did you pay for medicines? available. This gives an idea whether 36. How much did you pay for other some services are underutilized because items such as cotton, gloves, antisep­ people are simply not aware of them. tic, or syringes? Remember that the client will not use 37. How much did you pay for registra­ our exact terms. Interpret her comments tion card/membership? into the categories to the best of your 38. How much did you pay for travel? ability. If the client says "STD," or "HIV," 39. How much did you pay for any you may probe with "What kind of SID other services or fees? or HIV services are usually provided?" in In the inventory, the health facility will re­ order to come closer to the coding cat­ port in detail how much it charges FP cli­ egories available. ents for their services. The information on the amount actually paid by clients will 31. Apart from this facility, is there any reveal the true cost of services to individu­ other place near your home where als (including travel, etc.) versus the price you can go for family planning? charged by the health facility. 32. (Ifyes) What type of facility is it? Clients may know the total amount 33. What would you say is the main rea­ paid without knowing how the charges son you did not go there for family were divided. If this is the case, make a planning? note in the margin with the total amount. A client's choice of facilities is important because it may have been motivated by 40. Overall, do you feel that the total the quality of services she experiences. cost of obtaining services is much These three questions address those cli­ too expensive, a little too expensive, ents who have decided to come to this or acceptable to you? facility rather than another. Because the burden of expenses can only If the client indicates there is another be judged relative to a client's income, this facility close to her home or workplace, question gives the client the chance to as­ or another place she regularly visits, sess the difficulty she has in paying for code question 31 accordingly. Then services, even if the cost is quite low. questions 32 and 33 should be asked, and the client should be encouraged to 41. I understand that your main pur­ think about only one other facility, the pose for coming to the health facil­ one closest to her home or workplace. ity today was (insert purpose). Is In question 33, the client may mention this correct? more than one reason. Encourage her to This is a filter question to determine decide on one main reason. where you should go next in the ques-

Family planning client exit interview: question-by-question guide • 102 tionnaire. Depending on the client's physically receiving anything, count her main reason for the visit, we ask differ­ as "yes." ent questions. Therefore, it is very im­ portant to correctly identify the client's 46. (If no) What is the main reason you main reason for attending the clinic. did not obtain a contraceptive Look at page 68 to see the main rea­ method today? son for the client's visit. Then, read ques­ If there is more than one reason, probe tion 41 to check if the main reason has for the main reason. been correctly recorded. Ifso, then circle the reason again in question 41 and skip 47. Which method(s) didyou accepttoday? to the appropriate question. If not, then As with question 45, this question gets ask the client the correct purpose of her at the method the client decided to use visit, circle her answer, and then skip to today. If she decided to use injectables, the appropriate question number. but did not receive the injection today, tick injectable. Likewise, if she chose For new acceptors LAM or natural family planning, which 42. Just to make sure, I understand that do not involve physically receiving any­ you were not using a contraceptive thing, tick those methods. method when you came to the facil­ ity today. Is it correct that you were 48. Did the provider mention any other not using a method? methods to you? The purpose of this question is to make 49. Did the provider tell you that you one last check to see whether we have can switch methods ifyou are not classified the client correctly before we happy with this method? ask more questions. 50. Did the provider tell you another source of supply or follow-up for 43. Have you ever used any contracep­ your method? tive method in the past? The observation will record whether all 44. (If yes) Which method(s) have you three of these items took place. These ever used? questions are asked again in the exit in­ Methods used by husband/partnerCs) terview, and the results will be com­ such as condom, vasectomy, and with­ pared with the observation. This will drawal are attributed to the client as well. reveal whether information was effec­ tively communicated to the client. 45. Did you get a contraceptive method during this visit? 51. Is there some method other than This question gets at the method the cli­ the one you accepted today that you ent decided to use today. If she decided would have p1"eferred to use? to use injectables, but did not receive 52. (If yes) Which method would you the injection today, count her as "yes." have preferred to use most? Likewise, if she chose LAM or natural Research suggests low continuation/satis­ family planning, which do not involve faction if clients do not obtain their pre-

Family planning client exit interview: question-by-question guide • 103 ferred method, independent of the techni­ drawal are attributed to the client cal effectiveness of the method. Thus we as well. are very interested in whether they re­ ceived their preferred method, and what 57. Are you planning to continue using that preferred method might be. Again, this method? this information will also be recorded in Note that if the client is not going to the observation, and those results can be continue this method, then she is compared with these. Remember to ask treated as a revisit who had a problem, question 52 only if the client answers and is skipped to that section. She will "yes" to question 51. be asked questions on why she decided to stop or switch methods. 53. Why are you not going to use this preferred method? 58. I would now like to ask you about This will be recorded in the observation how to use (read method). as well, which will reveal whether cli­ In cases where the clients accepted dual ents who are contraindicated from a or multiple methods-such as condoms method, for example, are aware that that and spermicide, or pills and condoms­ is the reason for not using that method. you are instructed to circle the most ef­ fective method accepted and to ask only 54. I would now like to ask you about about the most effective method. how to use (read method). In cases where the clients accepted dual For revisit clients (problems with or multiple methods-such as condoms method or wanting to change or stop) and spermicide, or pills and condoms­ 59. Just to make sure, I understand that you are instructed to circle the most ef­ you were using a contraceptive fective method accepted and to ask only method when you came to the facil­ about the most effective method. ity today. Is it correct that you were using a method? For revisit clients (withoutproblems) The purpose of this question is to make 55. Just to make sure, I understand that one last check to see whether we have you were using a contraceptive classified the client correctly for the fol­ method when you came to the facil­ lowing questions. ity today. Is it correct that you were using a method? 60. Which method(s) were you using? The purpose of this question is to make Methods used by husband/partnerCs) such one last check to see whether we have as condoms, vasectomy, and withdrawal classified the client correctly for the fol­ are attributed to the client as well. lowing questions. 61. Is it correct that you had a problem, 56. Which method(s) were you using? wanted to change methods or Methods used by husband/partnerCs) wanted to stop family planning? such as condoms, vasectomy, and with- This question checks that the client is

Family planning client exit interview: question-by-question guide • 104 truly a revisit client who experienced have been given counseling and informa­ problems. If not, then she is treated as a tion as though they were new clients. normal revisit client, and switched to the proper section. 68. Did the provider mention any other methods to you? 62. What was the main problem you 69. Did the provider tell you that you had, or the main reason you wanted can switch methods ifyou are not to change or stop? happy with this method? Ifthere is more than one reason, encour­ 70. Did the provider tell you another age the client to select her main reason. source of supply or follow-up for your method? 63. (Ifhad medical side effects) When The observation will record whether all you rust decided to use this method, three of these items took place. These were you told that this problem questions are asked again in the exit in­ might happen? terview, and the results will be com­ 64. (Ifyes) Were you told what to do pared with the observation. This will about the problem? reveal whether information was effec­ If a client is told about side effects and tively communicated to the client. how to manage them when she accepts a method, then she has a greater chance 71. I would now like to ask you about of continuing to use the method if the how to use (read method). side effects occur. This question deter­ In cases where the clients accepted dual mines whether clients who experience or multiple methods-such as condoms side effects had been informed about and spermicide, or pills and condoms­ them previously, even if that information you are instructed to circle the most ef­ did not come from this facility. fective method accepted and to ask only about the most effective method. 65. After this consultation today, do you feel that you are getting appropriate Forpill users assistance for your particular needs? 72. When a woman first starts using the This is a satisfaction question, aimed spe­ pill, at what time in the menstrual cifically at those clients who need special cycle do you think she should start attention for the problems they have been taking it? experiencing with their methods. 73. How often do you think a woman should take her contraceptive pills? 66. What are you now going to do about 74. If a woman forgets to take the pill family planning? for one day, what do you think she 67. (If changing method) What should do? method(s) will you now be using? 75. Does the pill protect a woman These two questions will identify those against STDs/HIV? clients who are switching methods. These These four questions are basic knowl­ clients are important because they should edge questions about the pill. The "cor-

Family planning client exit interview: question-by-question guide • 105 rect" answers for 72,73, and 74 are "1," 83. As far as you know, what problems, and for 75 it is "3." if any, maya woman experience with an IUD? 76. As far as you know, what problems, 84. When do you think a woman should if any, maya woman experience come back for the f"ust check-up after when taking the pill? an IUD insertion? 77. Apart from the regular return or re­ 85. Apart from the regular check-up vis­ supply visit, for what problems, if its, for what problems, ifany, do you any, do you think a woman taking think a woman with an IUD should pills should come back to the facility? come back to the facility? These are also knowledge questions, 86. How many years do you think a but there is no "correct" answer for ei­ woman can keep using an IUD once it ther, since clients might know of any has been inserted? number of symptoms or problems. If the 87. Does the IUD protect a woman client does not mention any problems, against STDs/HIV? tick line 98. These are all general knowledge Be aware that the client may not use questions about the IUD. The client's our terms. Classify as well as you can responses will be compared with what the client says, using our terms. information that was observed to have been given to her during the con­ 78. Did the service provider give you a sultation. supply ofpills today? For questions 83 and 85, be aware 79. (If no) Where will you go to get your that the client will not use our terms. pills? Classify as well as you can what the cli­ Clients who have supplies and informa­ ent says, using our terms. If the client tion about resupply will probably achieve does not mention any problems, tick more continuity of method use. This infor­ line 98. mation will also be collected in the obser­ vation, so the results can be compared. 88. Go to q. 91.

80. Go to q. 101. For injectable users 89. Did you receive a contraceptive injec­ For IUD users tion today? 81. Did your visit to the facility today This question checks whether the client involve an IUD insertion, removal, actually received an injection today. or routine check-up? This question checks whether the client 90. (Ifno) Where will you go to get your actually received the IUD today. injection? This question addresses the supply of 82. As far as you know, how can a contraceptives. It was also recorded in woman check to be sure that the the observation, so the responses can be IUD is in place? compared.

Family plannin-g client exit interview: question-by-question guide • 106 91. Which type of injection did (will) ticularly important that clients are you get? aware of this protective property of Depo Provera is required every three condoms. months and Noristerat is required ev­ ery two months. If the client mentions 98. Did you receive a supply of con­ the time, rather than the type, code doms and/or spermicides (cream, appropriately. foam, jelly) today? 99. (If no) Where will you go to get 92. How often do you think you your condoms and/or spermicides should get this injection? (cream, foam, jelly)? As mentioned above, Depo Provera is 100. After you have finished this sup­ required every three months and ply of condoms and/or spermi­ Noristerat is required every two months. cides, where will you go to get more supplies? 93. As far as you know, what prob­ These questions get at contraceptive lems, ifany, do you think a woman supply, which is particularly complex may experience after having an with condoms, since they are often injection? available at many more outlets than 94. Apart from the regular return visit, other methods. for what problems, ifany, do you think a woman receiving injections For all clients should come back to the facility? 101. Now, I would like to ask you a few 95. Does an injection protect a woman questions about yourself. Are you against STDs/HIV? currently breastfeeding? These are general knowledge ques­ 102. (If yes) Are you breastfeeding ex­ tions for injectable users. Note that clusively, nearly exclusively, or there are no strictly "correct" answers supplemented regularly with food for questions 93 and 94, since clients and/or liquids? might know any number of symptoms If the client is breastfeeding during the or problems. Be aware that the client interview, do not ask the question but will not use our terms. Classify as well simply code "yes" on question 101. as you can what the client says, using Question 102 will be used to assess our terms. If the client does not men­ the appropriateness of progestin-only tion any problems, tick line 98. pills for this client, if that is the method she accepted. For this ques­ 96. Go to q. 91. tion, "exclusive breastfeeding" means only breast milk and nothing else; no For condom and spermicide users water, juice, or other foods. "Nearly ex­ 97. Do condoms/spermicides protect a clusively" means primarily breast milk woman against STDs/HIV? but sometimes some water or juice. This is the only knowledge question "Supplemented regularly" means breast for condom/spermicide users. It is par- milk with other liquids and foods also

Family planning client exit interview: question-by-question guide • 107 given. Try to determine which of these to determine the number of children to categories is closest to the current whom the woman has given birth. It ex- breastfeeding behavior of the client. eludes adopted children and children of other relatives presently living with her. 103. How old are you? Write the number of years mentioned 109. What is the age of your youngest by the client. If she doesn't know her child? age exactly, try to help her estimate Note that the age of the youngest with some important historical dates child should be recorded in months. as benchmarks as instructed in train- ing. If she has no idea what her age is, 110. Would you like to have any (more) write 98. children? Information from this question can be 104. What is your current marital status? used to check if the client received an This question should be answered us- appropriate contraceptive method. Ask ing the client's definition of marriage. "any" with a client who has no chil- dren. Ask "any more" with a client 105. (If not married) Do you have a who has one or more children. regular partner? A regular partner is someone with 111. (If yes) When would you like (a) whom the client has sexual inter- (the next) child? course on a regular basis, independent Information from this question can be of the frequency. used to check if the client received an appropriate contraceptive method. Ask 106. Have you ever discussed family "a" with a client who has no children. planning with your husband or Ask "the next" with a client who has regular partner? one or more children. 107. Does your husband or regular partner know that you use or that 112. Can you read and understand a let- you are planning to use family ter or a newspaper easily, with dif- planning? ficulty, or not at all? Discussion of family planning within 113. Which languages can you read and couples is a possible factor affecting understand? family planning use and continuation. 114. What is the highest level of school These questions are also asked of MCH you attended? clients, so the results can be compared 115. What is your religion? between FP and MCH clients. These four questions address the gen- eral socio-economic status of the cli- 108. How many living children ofyour ents. This can be used in designing own do you have? programs, producing appropriate IEC Emphasize the words "living" and materials, and arranging services in so- "your own." This question is intended cially and culturally acceptable ways.

Family planning client exit interview: question-by-question guide • 108 In question 114, note that we are 120. Have you ever heard of HIV or enquiring about "attended," not neces­ AIDS, or are you not sure? sarily"completed." 121. As far as you know, what are the ways to get HIV/ AIDS? 116. To end with, I would like to ask Be aware that the client may not use you some questions about other our terms when describing transmis­ reproductive health issues. I sion routes. Classify as well as you can would like to remind you that the what the client says, using our terms. information you provide will re­ If the client does not mention any main strictly confidential, and that problems, tick line 98. you do not have to answer any question you do not want to. 122. Do you know of any ways you can Sometimes a woman can become protect yourselffrom sexually pregnant when she is not ready to transmitted diseases including be. In the past, have you ever HIV/AIDS? been pregnant at a time when 123. (Ifyes) What are these ways of you were not ready for the protecting yourself? pregnancy? These knowledge questions are ex­ 117. (If yes) What did you do the last tremely important. Note that although time this happened to you? HIV/AIDS is itself a sexually transmit­ These questions are sensitive, but are ted disease, clients (and providers) usually answered when the inter­ may often think of it as a separate and viewer has developed a rapport with distinct category. the client, and is straightforward and nonjudgmental. For this reason, these 124. How many sexual partners have questions have been placed at the end you had in the past 12 months? of the interview, after the client is Write the number of partners the cli­ used to being asked questions. ent mentions. If she says none, end the interview by thanking the client 118. As far as you know, are there any for her time and assistance. diseases that can be transmitted through sexual intercourse? 125. Did you have sex with any new 119. From what you've heard or read, partner(s) in the past 12 months? what are some common signs and 126. (If yes) Did you use a condom the symptoms of sexually transmitted first time you had sex with your diseases? most recent new partner? Be aware that the client may not use These questions address the amount our terms when describing symptoms. of risk clients are generally exposed Classify as well as you can what the to. In question 126, emphasize that client says, using our terms. If the cli­ we are asking about the first time you ent does not mention any problems, had sex with your most recent new tick line 98. partner.

Family planning client exit interview: question-by-question guide • 109 Staff interview

This instrument gathers information on the The codes presented in brackets {} in this training, knowledge, and practices of family instrument are suggested variable names for planning providers. The results of these in­ each question or tick mark. These names are terviews help program planners to design referred to in the analysis plan (beginning training programs targeted to the specific on page 162). Keep in mind, however, that needs of staff. This information can also be they would not appear on the actual ques­ compared to information from the observa­ tionnaires used by researchers in the field. tions, to see how effectively provider knowl­ See instrument on following pages. edge is translated into provider actions.

Staff interview • 110 Country Name Situation Analysis Study Questionnaire number: _ {SID}

Interview for Staff Providing Family Planning / Reproductive Health Services at the Service Delivery Point

INSTRUCTIONS TO INTERVIEWER: All health facility staff who are responsible for providing family planning should be interviewed individually and in private at the end of the working day. It should be made clear that you are seeking their assistance in finding ways of improving the functioning and quality of the services offered by facilities in general, and are not evaluating the performance of the facility or of themselves individually. For each item, please circle the response or describe as appropriate.

Health facility visited (name): {HFNAME}

Health facility code: {HFCODE}

District (name): {DISTNAME}

District code: {DISTCODE}

Village/town (name): {TOWNNAME}

Village/town code: {TOWNCODE}

Study staff number: {STAFFID} Day _ Month _ Date of visit: Year --- {DATE}

Type of health facility: {TYPE} Type of sector: {SECT} 1 Referral Hospital 1 Government 2 District Hospital 2 FPA 3 Primary Hospital 3 Mission 4 Rural Health Center 4 Private 5 Maternity 5 Other 6 Health Post 7 Pharmacy Locality: {LOC} 8 CBD 1 Rural 9 Other 2 = Urban

Designation of staff member: {DESIG} 1 Doctor 2 Nurse 3 Nurse-midwife 4 CBD 5

Name of observer: ------Signature of team leader: _

Staff interview • 111 Read greeting:

We are carrying out a survey of health facilities that provide reproductive health services to find ways of improving services. We would be interested to know about your experiences so far with providing family planning services. Could I ask you some questions about this? Please be assured that this discussion is strictly confidential, and your name is not being recorded. Also, you are not obliged to answer any question you don't want to, and you may withdraw from the interview at any time. May I continue?

(If the provider agrees to continue, ask if she has any questions. Respond to questions as appropriate, then ask q.1

If the provider does not agree to continue, thank her and go to the next interview.)

Experience and training in FP/MCH/STD services

1. I'd like to ask you about services you Tick if yes provide to clients at this facility. Do you yourself provide (read 1-18) to clients at this health facility?

1. Family planning {Sl Xl}

2. Antenatal care {S 1X2} 3. Maternity care/delivery services {S 1X3}

4. Postnatal care {SlX4} 5. HIV/AIDS counselling/IEC {SlX5}

6. HIV/AIDS testing {Sl X6}

7. Other STD counselling/IEC {Sl X7}

8. Other STD diagnosis {51 X8}

9. Other STD treatment {51 X9}

10. Child immunization {51Xl0}

11 . Child growth monitoring {51Xll}

12. Infertility consultation {51X12} 13. Oral rehydration therapy {SlX13}

14. Treatment of incomplete abortion {51X14}

15. Nutrition counselling {51 X15}

16. Curative services - client {SlX16}

17. Curative services - child {51 X17}

18. {S1X18}

Staff interview • 112 2. How long have you been working here at this facility? {S2}

years 00 Less than six months (Round to nearest year) 98 Don't know

3. How many years ago did you finish your basic training? {S3}

years ago 00 Less than six months (Round to nearest year) 97 No basic training 98 Don't know

4. Did your basic 5. Have you ever training cover had refresher (read 1-12)? training in (read 1-12)? (Tick if yes) (Tick if yes)

1. Family planning {S4X1} {S5X1 }

2. Antenatal care {S4X2} {S5X2}

3. Maternity carel delivery services {S4X3} {S5X3}

4. Postnatal care {S4X4} {S5X4}

5. Child immunization {S4X5} {S5X5}

6. Child growth monitoring {S4X6} {S5X6}

7. Infertility consultation {S4X7} {S5X7}

8. Oral rehydration therapy {S4X8} {S5X8}

9. Treatment of incomplete abortion {S4X9} {S5X9}

10. Nutrition counselling {S4X10} {S5X10} 11. {S4X11 } {S5X11}

12. {S4X12} {S5X12}

Staff interview • 113 6. Have you attended any refresher or post-basic training courses specifically on family planning clinical skills, family planning program management, or HIVISTD counselling and treatment? {56}

1 = Yes 2 = No (to q.9) 98 = Don't know (to q.9)

7. Did that training 8. (If topic covered) How include long ago was that (read 1-19)? training? o = less than one year (Tick if yes) 98 = Don't know

1. General clinical skills in FP {57X1 } {S8X1 } years

2. FP counselling {S7X2} {S8X2} years

3. IUD insertion I removal {S7X3} {S8X3} years

4. NORPLANT® insertion I removal {S7X4} {S8X4} years

5. MULA (surgical procedure) {S7X5} {S8X5} years

6. Vasectomy (surgical procedure) {S7X6} {S8X6} years

7. Exclusive breastfeeding (LAM) {S7X7} {S8X7} years

8. Natural family planning {S7X8} {S8X8} years

9. Management {S7X9} {S8X9} years

10. Supervision {S7X10} {S8X10} years

11 . Recordkeeping {S7X11 } {S8X11 } years

12. Stockkeeping {S7X12} {S8X12} years

13. STD risk assessmentl screening {S7X13} {S8X13} years

14. STD counselling {S7X14} {S8X14} years

15. STD laboratory diagnosis {S7X15} {S8X15} years

16. Syndromic approach to diagnosis {S7X16} {S8X16} years and treatment

17. HIV/AIDS counselling {S7X17} {S8X17} years

18. HIV/AIDS testing {S7X18} {S8X18} years

19. Other: {S7X19R} {S7X19} {S8X19} years

Staff interview • 114 FP practices

9. In the last 3 months, have you yourself actually provided family planning to clients? {S9}

1 = Yes 2 = No (to q.32) 98 = Don't know (to q.32)

10. (If yes) Which methods have you yourself Tick if provided actually provided in the last 3 months? (Read 1 -15)

1. Combined. pill {S10X1}

2. Progestin-only pill {S 1OX2}

3.IUD {S10X3}

4. Injectable {S10X4}

5. NORPLANT@ {S10X5}

6. Condom {S10X6}

7. Diaphragm {S10X7}

8. Spermicide {S10X8}

9. Female sterilization (MULA) {S10X9}

10. Vasectomy {S10X10}

11 . Natural family planning {S10X11}

12. Exclusive breastfeeding (LAM) {S10X12}

13. Emergency FP {S10X13}

14. Other: {S10X14R} {S10X14}

15. {S10X15}

Staff inteNiew • 115 11, Is there a minimum age below 12. (If yes on q.11) which you yourself will not What is that prescribe (read 1-5), in the minimum age? absence of medical contraindications? (Tick if yes)

1. Pill (CaC) {S11X1} Age: {S12X1}

2. Condom {S11X2} Age: {S 12X2}

3. IUD {S11X3} Age: {S12X3}

4. Injectable {S11X4} Age: {S12X4}

5. Sterilization {S11X5} Age: {S12X5}

13. Is there a maximum age above 14. (If yes on q. 13) which you yourself will not What is that prescribe (read 1-5), in the maximum age? absence of medical contraindications? (Tick if yes)

1. Pill (CaC) {S13X1 } Age: {S14Xl}

2. Condom {S13X2} Age: {S14X2}

3. IUD {S13X3} Age: {S14X3}

4. Injectable {S13X4} Age: {S14X4}

5. Sterilization {S13X5} Age: {S14X5}

8taff interview • 116 15. Is there a minimum number of 16. (If yes) What is children a woman must have that minimum before you yourself will number of children? prescribe (read 1-5), in the absence of medical contraindications? (Tick if yes)

1. Pill (COC) {S15Xl} Number: {S16Xl}

2. Condom {S 15X2} Number: {S 16X2}

3. IUD {S 15X3} Number: {S 16X3}

4. Injectable {S15X4} Number: {S16X4}

5. Sterilization {S15X5} Number: {S16X5}

17. Would you yourself prescribe 18. Do you require a (read 1-5) to an unmarried husband's consent woman, in the absence of before you will medical contraindications? provide (read 1-5)? (Tick if yes) (Tick if yes)

1. Pill (COC) {S17Xl} {S18Xl}

2. Condom {S17X2} {S18X2}

3. IUD {S17X3} {S18X3}

4. Injectable {S17X4} {S18X4}

5. Sterilization {S 17X5} {S18X5}

Staff interview • 117 19. Are there methods of family 20. Are there methods of family planning that you planning that you recommend for most people recommend for most people who would like to delay or who would like to have no space their next birth, more children, assuming assuming there are no there are no contraindications? {S 19} contraindications? {S20}

1 = Yes (to q.19al 1 = Yes (to q.20a) 2 = No (to q.201 2 = No (to q.21) 3 = Depends on client's 3 = Depends on client's health (to q.201 health (to q.21 1 4 = Depends on client's 4 = Depends on client's preference (to q.201 preference (to q.21) 99 = No response (to q.201 99 = No response (to q.21)

19a. What are those methods? 20a. What are those methods?

Do not read methods, but probe with"Any other methods?" Tick if mentioned.

1. Combined pill {S19AX1} {S20AX1 }

2. Progestin-only pill {S19AX2} {S20AX2}

3. IUD {S19AX3} {S20AX3}

4. Injectable {S19AX4} {S20AX4} 5. NORPLANT@ {S19AX5} {S20AX5}

6. Condom {S19AX6} {S20AX6}

7. Diaphragm {S19AX7} {S20AX7}

8. Spermicide {S19AX8} {S20AX8}

9. Female sterilization {S19AX9} {S20AX9}

10. Vasectomy {S19AX10} {S20AX10}

11 . NFP {S19AX11 } {S20AX11 }

12. LAM {S19AX12} {S20AX12}

{S19AX13R} {S19AX13} {S20AX13} 13. Other: {S20AX13R}

Staff interview • 118 21. Are there methods of family 22. Are there methods of family planning that you would not planning that you would recommend for clients with never recommend under any an RTI/STD? {S21} circumstances? {S22}

1 = Yes (to q.21al 1 = Yes (to q.22a) 2 = No (to q.22) 2 = No (to q.23) 3 = Depends on client's 3 = Depends on client's health (to q.22) health (to q.23) 4 = Depends on client's 4 = Depends on client's preference (to q.22) preference (to q.23l 99 = No response (to q.22) 99 = No response (to q.23)

21 a. What are those methods? 22a. What are those methods?

Do not read methods, but probe with"Any other methods?" Tick if mentioned

1. Combined pill {S21AX1} {S22AXl }

2. Progestin-only pill {S21 AX2} {S22AX2}

3. IUD {S21AX3} {S22AX3}

4. Injectable {S21AX4} {S22AX4}

5. NORPLANT@ {S21AX5} {S22AX5} .

6. Condom {S21AX6} {S22AX6}

7. Diaphragm {S21AX7} {S22AX7}

8. Spermicide {S21AX8} {S22AX8}

9. Female sterilization {S21AX9} {S22AX9}

10. Vasectomy {S21AX10} {S22AX10}

11. NFP {S21 AX11} {S22AXll }

12. LAM {S21AX12} {S22AX12}

{S21AX13R} {S21AX13} {S22AX13} 13. Other: {S22AX13R}

8taff interview • 119 23. What do you do for a new client who wants the pill or another hormonal method but is not having her menses? Tick if mentioned

(Do not read, but probe with II Anything else? ")

1. Perform a pregnancy test {S23X1 }

2. Tell her to come back at next menses {S23X2}

3. Try to induce menses {S23X3}

4. Supply condoms and ask her to return with menses {S23X4}

5. Supply hormonal method {S23X5}

6. Supply hormonal method and condoms and ask her to use {S23X6} condoms until her menses

7. Other: {S23X7R} {S23X7}

24. How many packets of combined pills do you routinely supply to a pill client who has successfully used the pill for one year or more? {S24}

packets 99 = other response

Staff interview • 120 Reproductive health practices

25. If a pill client comes for a check-up/resupply and she appears to be at high risk of infection with an STD or HIV/AIDS, what advice would you give? (Do not read list. Circle all that apply.)

1 Continue to use the pill alone {S25X1} 2 Continue with the pill but use a condom also {S25X2} 3 = Switch from the pill to the condom {S25X3} 4 Stop using any type of contraception {S25X4} 5 Counsel client on STDs/HIV or refer for counseling {S25X5} 6 Other: {S25X6R} {S25X6} 98 = Don't know {S25X98}

26. If you think that a client has an STD, what do you do for her? (Do not read list but probe by asking, "Anything else?") Tick if mentioned

1. Request laboratory tests {S26X1 }

2. Diagnose {S26X2}

3. Treat {S26X3}

4. Refer for diagnoses {S26X4}

5. Refer for treatment {S26X5}

6. Provide counselling {S26X6}

7. Refer for counselling {S26X7}

8. Issue a contact or partner notification slip {S26X8}

9. Other: {S26X9R} {S26X9}

Staff interview • 121 27. If you think that a client has HIV/AIDS, what do you do for her? Tick if mentioned (Do not read list but probe by asking, "Anything else?")

1. Request HIV test {S27X1}

2. Refer for HIV test {S27X2}

3. Provide condoms {S27X3}

4. Provide or refer for treatment of complications {S27X4}

5. Provide counselling {S27X5}

6. Refer/request for counselling {S27X6}

7. Issue contact or partner slip {S27X7}

8. Other: {S27X8R} {S27X8}

28. Do you request a syphilis test for antenatal clients you see at this health facility? {S28}

1 Yes 2 No

29. How comfortable are you discussing sexual behavior related to STD/HIV with clients? Would you say you are very uncomfortable, somewhat uncomfortable, comfortable, or very comfortable? {S29}

1 Very uncomfortable 2 Somewhat uncomfortable 3 Comfortable 4 Very comfortable 99 = No response

30. As far as you know, do women come to this facility for advice on termination of pregnancies? {S30}

= Yes 2 = No 98 = Don't know

31. As far as you know, do women come to this facility for medical treatment as a consequence of an incomplete, induced abortion? {S31}

1 = Yes 2 = No 98 = Don't know

Staff interview· 122 Socio-demographic characteristics

32. To end with, I would like to ask you a few questions about yourself. How old are you? {S32}

years old 98 = Don't know

33. What is your current marital status? (Probe for exact status) {S33}

1 Married/monogamous 2 Married/polygamous 3 Cohabiting/living together 4 Single, never married 5 Divorced/separated 6 Widowed

34. How many living children of your own do you have? {S34}

children 99 = No response

35. What is your religion? {S35}

1 Protestant 2 Catholic 3 Moslem 4 African Spiritual 5 None 6 Other: {S35R} 98 = Don't know

36. Gender: {S36}

1 Female 2 Male

Staff interview • 123 37. What methodls) of family planning are you or your partner currently using? Tick if mentioned (Do not read list, but probe by asking, "Any other methods?")

1. Combined pill {S37Xl }

2. Progestin-only pill {S37X2}

3. IUD {S37X3}

4. Injectable {S37X4}

5. NORPLANT® {S37X5}

6. Condom {S37X6}

7. Diaphragm {S37X7}

8. Spermicide {S37X8}

9. Female sterilization {S37X9}

1O. Vasectomy {S37Xl0}

11. Natural family planning {S37Xll }

12. Exclusive breastfeeding (LAM) {S37X12}

13. Other: {S37X13R} {S37X13}

77. None {S37X77}

Read closing:

Thank you very much for having spent so much time with me.

Staff interview • 124 Staff interview: question-by­ 1. I'd like to ask you about services question guide you provide to clients at this facility. The first person to be interviewed is usually Do you yourself provide (various the staff person in charge of family planning methods/services) to clients at this services. It is necessary to obtain this health facility? person's permission to interview other staff, The purpose of this question is to deter­ and to make it clear that the interviews are mine all the services the staff person not an evaluation of individual staff or facil­ provides to clients. You should make ity performance. Also, staff names will not sure that the staff person herself is the be recorded on any of the interview one who provides the services. For each schedules. After permission is obtained, service listed, ask the provider "Do you all other family planning providers should yourselfprovide (the service listed)," be interviewed. emphasizing the word "yourself." The staff member in charge of family planning is the same person who will be 2. How long have you been working asked to assist in conducting the inventory. here at this facility? Because of this, the research team needs to Record the number of years. If less coordinate the taking of the inventory with than 6 months, record 00. If more than the interview so as not to take too much of six months but less than 12 months, a single staff person's time. record 1. The interviews should be carried out at a 3. How many years ago did you finish time when staff are not actively engaged in your basic training? the delivery of services to clients, which is 4. Did your basic training cover (vari­ usually in the afternoon. In all cases, every ous topics)? effort should be made to minimize the im­ Emphasize the words "basic training." pact of drawing staff away from their other, Basic training refers to the most ad­ normal duties. (See the section on "Tips for vanced, long-term training the staff per­ conducting a good interview," page 23 for son received for their present position. more information.) For example, a nurse/midwife might You should be able to fill out the informa­ have been through the same training as tion on the cover page before the interview a nurse, plus some additional long-term begins. If you are not sure about any of the midwifery training. In this case, "basic identifying codes, ask your Team Leader. training" refers to the midwifery training Write (do not sign) your name in the box at because it is the most advanced she re­ the bottom of the page. When you have ceived, and it qualifies her for her posi­ completed the interview, your Team Leader tion. For a nurse, "basic training" would will review it and sign below your name. be the nurse training only. Before starting the interview, be sure to read the greeting as printed on the interview 5. Have you ever had refresher train­ schedule and obtain the "informed consent" ing in (various topics)? of each individual provider. Emphasize the words "refresher training."

Staff interview: question-by-question guide • 125 Refresher training refers to training re­ not require contraceptive supplies or in­ ceived after basic training and usually is vasive procedures, providing informa­ of relatively short duration. Sometimes this tion and education to the client training is referred to as in-service training. constitutes "actually providing" the method. 6. Have you attended any refresher or post-basic training courses specifi­ 11. Is there a minimum age below cally on family planning clinical which you yourself will not pre­ skills, family planning program scribe (various methods), in the ab­ management, or HIV/STD counsel­ sence of medical contraindication. ing and treatment? 12. (Ifyes on q. 11) What is that mini­ 7. Did that training include (various mum age? FP topics)? 13. Is there a maximum age above 8. (If topic covered) How long ago was which you yourself will not pre­ that training? scribe (various methods), in the ab­ These questions begin to focus on fam­ sence of medical contraindications? ily planning training in particular. Note 14. (If yes on q. 13) What is that maxi­ that question 7 is only asked if the pro­ mum age? vider answers "yes" to question 6. Fill in These questions determine whether the the column for question 8 only for those staff member uses age as a sole criteria topics in which the provider was for providing a contraceptive method to trained. If the training occurred less than a client. These questions are some of 12 months prior, record O. the most complex in the Situation Analysis, and you may find that they 9. In the last 3 months, have you your­ will require some extra explanation to self actually provided family plan­ the provider. ning to clients? First, ask if there is a minimum age 10. (If yes) Which methods have you below which the provider will not pre­ yourself actually provided in the last scribe methods. Emphasize the words 3 months? "you yourself." Note that this is in the These questions serve to identify the absence of medical contraindications­ providers who are actually providing FP this question is assumed to apply to services. In both questions, emphasize new family planning clients in good the words "you yourself." "Actually pro­ health. If the provider says yes, then ask vided" means that the staff person what that minimum age is and record it. physically gave a method to a client or Remember that the minimum age is performed a procedure such as a steril­ the age below which the staff person ization, an IUD insertion, or an injec­ will not provide the method under any tion. It does not mean merely referring a circumstances. For example, suppose a client to another provider or facility to provider says that she will not give pills receive the method. With regard to LAM to a girl of 14 years or below, unless the and NFP, since these two methods do girl is married. In this case, the provider

Staff interview: question-by-question guide • 126 has specified an exception to her rule this interview, even if she does so qui­ regarding age and she is not using age etly with clients. Reassure the provider as the sole criteria. In this case, you that the interview is strictly confidential. might ask if there is a minimum age for However, if she would still like to report married clients, which would get at the according to the policy, record her answer. provider's minimum age requirement, regardless of the client's circumstances. 15. Is there a minimum number of chil­ If the provider cannot specify an age dren a woman must have before you that she would use as the sole criteria, yourself will prescribe (various record that there is no minimum limit. methods), in the absence of medical The same process applies to the contraindications? maximum age. First ask if the provider 16. (If yes) What is that minimum num­ has such a maximum limit, emphasizing ber of children? the words "you yourself," and then ask The purpose of question 15 is to find what the limit is. Again, this applies to out if the staff person uses a minimum new, healthy family planning clients only, number of children as a sole criteria for and cases in which age is the sole criteria. providing a contraceptive method to a Please record the ages that providers client. For example, the provider may give, regardless of how extreme they say that she requires a client to have may appear. For example, a provider two children before giving the inject­ may say that her maximum age for able, except if she is over 35. In that condoms is 100. This may seem to be case, the provider is using age as an­ intuitively equivalent to "no maximum other criteria, so the number of age," but it should be recorded nonethe­ children alone is not a rigid barrier. less. These cases will be dealt with in Code this as no barrier. Note also that the data analysis. this involves new family planning Also remember that as you ask these clients who are otherwise healthy, so questions, and especially if you engage the provider does not have to consider in a clarifying conversation with the pro­ any contraindications. Emphasize vider, never suggest sample ages. That is, the words "you yourself" in do not explain with, "Do you feel that a question 15. client who is 12 is too young for the pill?" Sometimes, specific program policies Ifyou mention a number, even as an ex­ direct providers not to give methods to ample only, it may bias the response. clients who have no children. For ex­ Sometimes, specific program policies ample, IUDs are sometimes barred to direct providers not to give methods to women with no children, as a matter of clients outside of certain age ranges. For policy, not as a matter of provider dis­ example, sterilization is sometimes cretion. In those cases, the provider may barred to women under 35, as a matter be hesitant to contradict the policy in of policy, not as a matter of provider dis­ this interview, even if she does so qui­ cretion. In those cases, the provider may etly with clients. Reassure the provider be hesitant to contradict the policy in that the interview is strictly confidential.

Staff interview: question-by-question guide • 127 However, if she would still like to 20. Are there methods of family plan­ report according to the policy, record ning that you recommend for most her answer. people who would like to have no more children, assuming there are 17. Would you yourself prescribe (vari­ no contraindications? ous methods) to an unmarried 20a. What are those methods? woman, in the absence of medical 21. Are there methods of family plan­ contraindications? ning that you would not recom­ 18. Do you require a husband's consent mend for clients with an RTI/STD? before you will provide (various 21a. What are those methods? methods)? 22. Are there methods of family plan­ These two questions also address pro­ ning that you would never recom­ vider barriers, but they are much less mend under any circumstances? complex than the age or parity questions 22a. What are those methods? (11 through 16). They each result in a This sequence of questions addresses simple yes/no answers. However, they still the provider's attitudes toward particu­ require that the barrier is imposed as a lar methods, and the circumstances sole criteria. If a provider requires a under which she would provide them. husband's consent usually, but will waive In each case, ask the introductory that requirement if the client has a certain question (19, 20, 21, and 22), and if number of living children, then husband's the answer is "yes", ask the subordi­ consent is not the sole criteria. nate question about the specific meth­ Sometimes, specific program policies ods C19a, 20a, 21a, 22a). direct providers not to give methods to Questions 19 and 20 are concerned unmarried clients or clients without spou­ with spacing and limiting method rec­ sal consent. For example, pills are some­ ommendations given to new family times barred to single women as a matter planning clients who are healthy and of policy, not as a matter of provider dis­ have no contraindications. Question cretion. In those cases, the provider may 21 is about methods recommended for be hesitant to contradict the policy in this clients with an RTI/STD, assuming that interview, even if she does so quietly these clients are otherwise healthy. with clients. Reassure the provider that That is, they have no other the interview is strictly confidential. How­ contraindications. Question 22 asks ever, if she would still like to report ac­ about methods the provider would cording to the policy, record her answer. never recommend under any circum­ stances. Responses to this question are 19. Are there methods offamily plan­ rare, since most providers recognize ning that you recommend for most that all methods have appropriate ap­ people who would like to delay or plications in at least some circum­ space their next birth, assuming stances. Nonetheless, some there are no contraindications? informative provider biases have been 19a. What are those methods? identified through this question.

Staff interview: question-by-question guide • 128 23. What do you do for a new client These questions address providers' in­ who wants the pill or another hor­ tentions for treating clients suspected of monal method but is not having her having these conditions, which can be menses? compared to their actions in the obser­ Do not read the responses, but probe vation. Their actions may be hampered by asking "Anything else?" Be aware that by a lack of tests or materials, discom­ the provider may not use exactly the fort with discussing STDs, or lack of same language listed in the table; try to time, but these questions in the inter­ select the most appropriate response. view will determine what they would do in the best circumstances. In this way, 24. How many packets of combined any lapses in treatment of clients with pills do you routinely supply to a STD/HIV/ AIDS can be identified as pill client who has successfully used problems of provider training or prob­ the pill for one year or more? lems of implementation. The purpose of this question is to find out how many packets of pills providers 28. Do you request a syphilis test for intend to give to revisit pill clients. This antenatal clients you see at this information will be combined with in­ health facility? formation from the observation showing The purpose of this question is to deter­ how many cycles of pills clients actually mine if the provider normally or usually receive, and with information from the requests a syphilis test for antenatal cli­ inventory showing the status of pill ents. This is a measure of the integration stocks at that SDP. of FP and RH services.

25. Ifa pill client comes for a check-up/ 29. How comfortable are you discussing resupply and she appears to be at sexual behavior related to STD/HIV high risk of infection with an STD with clients? Would you say you are or HIV/ AIUS, what advice would very uncomfortable, somewhat un­ you give? comfortable, comfortable, or very This question enquires about provider comfortable? behavior that is difficult to observe, Le. Even if a provider is extremely techni­ what advice she would give to a client cally competent, she may feel socially who appeared to be at high risk of in­ prevented from discussing STDs/HIV fection with an STD or HIV/ AIDS. with clients. This question attempts to measure how comfortable providers feel 26. Ifyou think that a client has an in these situations. STD, what do you do for her? 27. Ifyou think that a client has HIY/ 30. As far as you know, do women come AIDS, what do you do for her? to this facility for advice on termina­ The treatment of clients with STDs or tion of pregnancies? HIV/ AIDS is an important subject for in­ 31. As far as you know, do women come tegrated family planning programs. to this facility for medical treatment

Staff interview: question-by-question guide • 129 as a consequence of an incomplete, 34. How many living children of your induced abortion? own do you have? These questions can be controversial, Emphasize the words "living" and "your especially in countries where abortion is own." For female providers, this ques­ illegal. For this reason, they are worded tion is intended to determine the num­ very carefully. Note that question 30 ber of children to whom she has given does not ask whether women actually birth. For male providers, this question receive advice about abortion or should determine the number of natural whether women actually receive abor­ children he has fathered. In both cases, tions themselves, but simply if women it excludes adopted children and chil­ come seeking such advice. Similarly, dren of other relatives presently living question 31 does not ask if women actu­ with them. ally receive treatment for incomplete abortions. Moreover, both questions 35. What is your religion? carefully avoid asking the individual 36. Gender? provider whether she is directly in­ These questions, along with others, volved with these clients, but only will serve to identify any large differ­ whether she is aware of their presence. ences in religion and gender among staff as opposed to clients. Such differ­ 32. To end with, I would like to ask you ences can sometimes be a barrier to a few questions about yourself. How services. Note that for question 36 old are you? there is no need to actually ask the If the provider does not know her age question; simply mark the correct precisely, try to help her estimate with response. some important historical dates as bench­ marks, as instructed in training. If the pro­ 37. What method(s) of family planning vider has no idea what her age is, write 98. are you or your partner currently using? 33. What is your current marital status? Do not read the list. Tick all methods This question should be answered using the staff person says she is using now. the provider's definition of marriage. Among those who are using methods, most will list only one, but some may list two. If the provider is not using a method, tick 77.

Staff interview: question-by-question guide • 130 MCH client exit interview

This instrument gathers information from will attract more FP clients. In this sense, MCH clients about the services they have the MCH client population is used as a just received as well as their attitudes toward proxy to gather information about the gen­ and use of family planning. Information eral population that is not currently using from MCH clients is useful in two ways. contraception. First, it can be compared with information The codes presented in brackets {} in this from the FP client exit interview. This helps instrument are suggested variable names for identify how FP clients differ from MCH cli­ each question or tick mark. These names are ents, and whether these differences can ex­ referred to in the analysis plan (beginning plain some of the FP clients' attitudes and on page 162). Keep in mind, however, that practices. Second, MCH client attitudes to­ they would not appear on the actual ques­ ward FP and awareness of FP services can tionnaires used by researchers in the field. assist managers in designing programs that See instrument on following pages.

MCH client exit interview • 131 Country Name Situation Analysis Study Questionnaire number: _ {MID}

Interview for MCH Clients Attending the Service Delivery Point

INSTRUCTIONS TO INTERVIEWER: This questionnaire should be used with female clients aged 15 - 45 years at the health facility who have not come for family planning. If possible, try to interview clients after rather than before the consultation. Ask the woman if she is willing to answer some questions about maternal and child health issues. It is essential that you gain her informed consent by reading the greeting before beginning the interview.

Health facility visited (name): {HFNAME}

Health facility code: {HFCODE}

District (name): {DISTNAME}

District code: {DISTCODE}

Village/town (name): {TOWNNAME}

Village/town code: {TOWNCODE}

Study client number: {CLlID}

Client's location/ward: {CLILOC}

Date of visit: Day __ Month Year {DATE}

Type of health facility: {TYPE} Type of sector: {SECT} 1 = Referral Hospital 1 Government 2 District Hospital 2 FPA 3 Primary Hospital 3 Mission 4 Rural Health Center 4 Private 5 Maternity 5 Other 6 Health Post 7 Pharmacy Locality: {LOC} 8 CBD 1 Rural 9 Other 2 = Urban

Timing of interview: {TIMING} 1 Before consultation 2 = After consultation

Name of observer:

Signature of team leader:

MCH client exit interview • 132 Read greeting:

Hello. We would like to improve the services provided by the facility and would be interested to find out about your experience today. I would like to ask you some questions about your visit today, and would be very grateful if you could spend some time answering these questions. I will not write down your name, and everything you tell me will be kept strictly confidential. Also, you are not obliged to answer any question you don/t want to, and you may withdraw from the interview at any time. May I continue?

(If the client agrees to continue, ask if she has any questions and respond to questions as appropriate. If she has had her consultation, ask q.1. If she has not had her consultation yet, skip to q. 26.

If the client does not agree to continue, thank her and go to the next interview.)

Client satisfaction

1. What was the main reason you visited the facility today? (Circle one.) {Ml}

1 Antenatal care 2 Maternity care/delivery services 3 = Postnatal care 4 HIV/AIDS counselling /IEC 5 HIV/AIDS testing 6 Other STD counselling /IEC 7 Other STD diagnosis 8 Other STD treatment 9 Child immunization 10 Child growth monitoring 11 Infertility consultation 12 Oral rehydration therapy 13 Treatment of incomplete abortion 14 Nutrition counselling 15 Curative services - client 16 Curative services - child 17 Other: {Ml R}

2. Overall, would you say you were satisfied with your visit to the facility today, or were you dissatisfied with your visit today? {M2}

1 Satisfied 2 Dissatisfied 3 Other: {M2R}

MCH client exit interview • 133 3. What other health services did you receive today? Tick if received (Read 1 - 17, excluding response on q.1)

1. Family planning {M3X1 }

2. Antenatal care {M3X2}

3. Maternity care/delivery services {M3X3}

4. Postnatal care {M3X4}

5. HIV/AIDS counselling {M3X5}

6. HIV/AIDS treatment {M3X6}

7. Other STD counselling {M3X7}

8. Other STD diagnosis {M3X8}

9. Other STD treatment {M3X9}

10. Child immunization {M3X10}

11 . Child growth monitoring {M3X11}

12. Infertility consultation {M3X12}

13. Oral rehydration therapy {M3X13}

14. Treatment of incomplete abortion {M3X14}

15. Nutrition counselling {M3X15}

16. Curative services - client {M3X16}

17. Curative services - child {M3X17}

77. No other services {M3X77}

4. Do you feel that you received the information and services that you wanted today? {M4}

1 Yes 2 = No 3 Partially 98 = Don't know

5. Do you feel that your consultation with the clinical staff was too short, too long, or about the right amount of time? {M5}

1 Too short 2 Too long 3 About right 98 = Don't know

MCH client exit interview· 134 6. During this visit, did you have any concerns about health issues that you wanted to discuss with the provider? {M6} 1 = Yes 2 = No (to q.8) 98 = Don't know (to q.8)

7. (If yes) Did the provider listen to your concerns to your satisfaction? {M7}

1 = Yes 2 = No 98 = Don't know

8. During this visit, did you have any questions you wanted to ask? {MB}

1 = Yes 2 = No (toq.11) 98 = Don't know (to q.11)

9. (If yes) Did the provider let you ask the questions? {M9}

1 = Yes 2 = No (to q. 1 1) 98 = Don't know (to q.11)

10. (If yes) Did the provider respond to your questions to your satisfaction? {Ml0}

1 = Yes 2 = No 98 = Don't know

11. During this visit, did the provider conduct any health examinations or procedures? {Mll}

1 = Yes 2= No (toq.14) 98 = Don't know (to q.14)

12. (If yes) Did the provider explain the examinations or procedures before they were performed? {M12}

1 = Yes 2 = No 98 = Don't know

13. Did the provider explain the results of the health examinations or procedures? {M13}

1 = Yes 2 = No 98 = Don't know

14. In your opinion, did you have enough privacy during your consultation with the service provider? {M14} 1 = Yes 2 = No 98 = Don't know

MCH client exit interview· 135 15. During the consultation, did you feel that the provider was easy to understand when explaining things to you, or did you feel that the provider was difficult to understand? {M15}

= Easy to understand 2 = Difficult to understand 98 = Don't know

16. About how long did you have to wait between the time you first arrived at this facility and the time you began receiving the services that you came for? {M16}

_____ minutes 98 Don't know (If no waiting time, to q.18)

17. Do you feel that the wait between the time you first arrived at this facility and the time you began receiving the services you came for was reasonable or too long? {M17}

1 = Reasonable 2 = Too long 98 = Don't know

18. If a friend of yours wanted the services that you came here for today, would you encourage her to come to this facility, or would you encourage her to go somewhere else? {M 18}

1 = Come to this facility 2 = Go somewhere else 98 = Don't know

19. What did you like most about your visit here today? {M19}

20. What did you dislike most about your visit here today? {M20}

21. If you could suggest one improvement to the services provided, what would it be? {M21}

MCH client exit interview • 136 lEe activities

22. During this visit, were you given or did you take any brochure or educational material to bring home? {M22} 1 = Yes 2 = No (to q.24) 98 = Don't know (to q.24)

23. (If yes) What was the subject(s) of that material? (Do not read list, but probe by asking, "Any other Tick if mentioned subjects?")

1. Family planning {M23Xl }

2. Antenatal/postnatal care {M23X2}

3. Delivery services {M23X3}

4. HIV/AIDS {M23X4)

5. Other STDs {M23X5}

6. Child welfare {M23X6}

7. Nutrition {M23X7}

8. Other: {M23X8R} {M23X8}

98. Don't know {M23X98}

24. Did you attend a group talk(s) at the facility today? {M24}

1 = Yes 2 = No (to q.26) 98 = Don't know (to q.26)

MCH client exit inteNiew • 137 25. (If yes) What topics were covered in the group talk(s)? (Do not read list, but probe by asking, "Any other topics?") Tick if mentioned

1. Family planning {M25X1 }

2. Antenatal care {M25X2}

3. Maternity carel delivery services {M25X3}

4. Postnatal care {M25X4}

5. HIV/AIDS {M25X5}

6. STD {M25X6}

7. Child immunization {M25X7}

8. Child growth monitoring {M25X8}

9. Infertility {M25X9}

10. Oral rehydration therapy {M25X10}

11 . Treatment of incomplete abortion {M25X11 }

12. Nutrition counselling {M25X12}

13. Curative services - clients {M25X13}

14. Curative services - children {M25X14}

15. Breastfeeding {M25X15}

16. Other: {M25X16R} {M25X16}

98. Don't know {M25X98}

MCH client exit interview • 138 Accessibility

26. Are the hours this facility is open convenient for you? {M26}

1 = Yes (to q.28) 2 = No 98 = Don't know (to q.281

27. (If no) What time would be most convenient to you? (Circle one.) {M27}

1 Earlier in morning 2 Over lunch hour 3 Afternoon 4 Evening / night 5 Weekends / holidays 6 Other: _ {M27R} 98 = Don't know

28. Have you ever been turned away from this facility during official working hours? {M28}

1 = Yes 2 = No 3 No previous experience with facility 98 = Don't know

29. How long did it take you to come here today? {M29}

minutes 98 = Don't know

30. What was the main means of transport that you used to get here? (Circle one.) {M30}

1 = Walked 2 = Donkey cart 3 = Bus / combi 4 = Bicycle 5 = Private car 6 = Other: {M30R}

MCH client exit interview • 139 31. As far as you know, what types of services are usually provided at this facility? Tick if mentioned (Do not read, but probe by asking, "Any other services?")

1. Family planning {M3l Xl}

2. Antenatal care {M3l X2}

3. Maternity care/delivery services {M3l X3}

4. Postnatal care {M3l X4}

5. HIV/AIDS counselling/lEe {M31X5}

6. HIV/AIDS testing {M3l X6}

7. Other STD counselling/IEC {M3l X7}

8. Other STD diagnosis {M3l X8}

9. Other STD treatment {M31X9}

10. Child immunization {M31Xl0}

11. Child growth monitoring {M31Xl1}

12. Infertility consultation {M3l X12}

13. Oral rehydration therapy {M31X13}

14. Treatment of incomplete abortion {M31X14}

15. Nutrition counselling {M31X15}

16. Curative services - client {M31X16}

17. Curative services - child {M31X17}

18. Other: {M3l X18R} {M31X18}

98. Don't know {M31X98}

32. Apart from this facility, is there any other place near your home where you can go for the same services that you came for here today? {M32}

1 = Yes 2 = No (to q.35) 98 = Don't know (to q.35)

33. (If yes) What type of facility is it? (Circle one. If more than one facility, choose nearest to home.) {M33} 1 CBD 2 = Health post 3 Health center 4 Hospital 5 Other: _ {M33R} 98 = Don't know

MCH client exit interview· 140 34. What would you say is the main reason you did not go there for the services? (Do not read list. Probe for the main reason and circle one.) {M34}

1 Inconvenient opening times 2 Takes too long to get there 3 Poor quality service 4 Fewer services available 5 Want to be anonymous 6 Have other reasons to come here (e.g. immunization services) 7 More expensive there 8 Prefer provider here 9 = Other: {M34R} 98 = Don't know

35. In the past 12 months, how 36. In the past 12 months, how many visits have you made to many visits have you made this facility/hospital for (read to any other facility/hospital 1-4)? for (read 1-4)?

1. Family planning {M35X1} visits {M36Xl } visits

2. Child welfare {M35X2} visits {M36X2} visits

3. Antenatal care {M35X3} visits {M36X3} visits

4. STD/HIV {M35X4} visits {M36X4} visits

37. Now I would like to ask you about the cost of travel and Record amount services that you have received from this clinic. How much (in local currency units) did you pay for (read 1-6)? 98 = Don't know

1. Consultation {M37Xl }

2. Medicines {M37X2}

3. Other items such as cotton, gloves, antiseptic, or syringes {M37X3}

4. Registration card/membership {M37X4}

5. Travel {M37X5}

6. Other: {M37X6R} {M37X6}

38. Overall, do you feel that the total cost of obtaining services is much too expensive, a little too expensive, or acceptable to you? {M38}

1 Much too expensive 2 A little too expensive 3 Acceptable 98 = Don't know

MCH client exit inteNiew • 141 Family planning knowledge and use

39. Now I would like to ask you some questions about having children. Do you know of any ways or methods that women and men can use to delay or prevent a pregnancy? {M39}

1 Yes 2 No (to q.49)

40. (If yes) Please tell me any 41. (If mentioned) As far as you such methods that you know know, is it possible to obtain of. this method at this health (Do not read but probe by facility?

asking, IIAny other methods?" Tick if (Tick if yes) mentioned.)

1. Combined pill {M40X1 } {M41X1} (or unspecified)

2. Progestin-only pill {M40X2} {M41 X2}

3. IUD {M40X3} {M41 X3}

4. Injectable {M40X4} {M41 X4}

5. NORPLANT@ {M40X5} {M41 X5}

6. Condom {M40X6} {M41 X6}

7. Diaphragm {M40X7} {M41 X7}

8. Spermicide {M40X8} {M41 X8}

9. Female sterilization {M40X9} {M41 X9}

10. Vasectomy {M40X10} {M41X10}

11 . NFP {M40X11 } {M41X11}

12. LAM {M40X12} {M41X12}

13. Other: {M40X13R} {M40X13} {M41X13}

42. Did you hear or see anything about family planning in this health facility today? {M42}

1 = Yes 2 = No (to q.44) 98 = Don't know (to q.44)

MCH client exit interview • 142 43. (If yes) Did you (read 1-5)? Tick if yes

1. See a family planning poster? {M43Xl }

2. See a family planning pamphlet, flip chart, or information sheet? {M43X2}

3. Hear about family planning during a health talk? {M43X3}

4. Hear about family planning during a consultation? {M43X4}

5. See samples of contraceptives? {M43X5}

44. Do you yourself approve or disapprove of couples using a method of family planning to avoid getting pregnant? {M44}

1 = Approve 2 = Disapprove 98 = Don't know / no opinion

45. Are you or your spouse/partner currently using any method to space, avoid or prevent a pregnancy? {M45} 1 = Yes 2 = No (to q.47) 98 = Don't know (to q.47)

46. (If yes) Which method? (Circle one.) {M46}

1. Combined pill (or unspecified) 2. Progestin-only pill 3. IUD 4. Injectable 5. NORPLANT® 6. Condom 7. Diaphragm 8. Spermicide 9. Female sterilization 10. Vasectomy 11. NFP (to q.49) 12. LAM (to q.49) 13. Other: {M46R}

47. Where do/did you go to get your current family planning method? {M47}

1 This health facility 2 Another health facility 3 Pharmacy/ shop/ chemist/ drugstore 4 CBD/FWE 5 Private doctor 6 Other: {M47R}

MCH client exit interview· 143 48. What is the main reason you obtain your method from that place and not somewhere else? (Do not read, but probe for main reason. Circle one.) {M48}

1 Only knows this source 2 Convenient opening times 3 Quality of services 4 Range of services 5 Can be anonymous 6 Close to home 7 Cost of methods 8 = Likes/trusts provider 9 Other: {M48R} 98 = Don't know

Sociodemographic characteristics

49. Now, I would like to ask you a few questions about yourself. Are you currently breastfeeding? {M49} 1 = Yes 2 No (to q.51)

50. (If yes) Are you breastfeeding exclusively, nearly exclusively, or supplemented regularly with food and/or liquids? {M50}

1 = Breastfeeding exclusively 2 Nearly exclusively 3 Supplemented regularly with food and/or liquids 98 = Interviewer unable to determine extent of supplementation

51. How old are you? {M51}

years 98 = Don't know

52. What is your current marital status? (Probe for exact status.) {M52}

1 Married / monogamous (to q.54) 2 Married / polygamous (to q.541 3 Cohabiting (to q.54) 4 Single, never married 5 Divorced / separated / widowed

53. (If not married) Do you have a regular partner? {M53}

1 = Yes 2 = No (to q.561

54. Have you ever discussed family planning with your husband or regular partner? {M54}

1 = Yes 2 = No 98 = Don't know

MCH client exit interview' 144 55. Do you think your spouse/partner approves or disapproves of your using a method to space or avoid a pregnancy? {M55}

1 = Approves 2 = Disapproves 98 = Don't know

56. How many living children of your own do you have? {M56}

children (If none, to q.58)

57. What is the age of your youngest child? {M57}

______months 98 = Don't know

58. Would you like to have any (more) children? (Circle one.) {M58}

1 = Yes 2 = No (to q.60) 3 Depends on husband (to q.60) 4 Depends on God (to q.60) 5 Not sure / undecided (to q.60)

59. (If yes) When would you like (a) (the next) child? (Circle one.) {M59}

1 Less than one year 2 One year 3 Between one and two years 4 Two years 5 More than two years 6 Any other response 98 = Don't know

60. Can you read and understand a letter or a newspaper easily, with difficulty, or not at all? {M60}

1 Easily 2 With difficulty 3 Not at all

61. Which languages can you read and understand? Tick if mentioned (Do not read but probe by asking, "Any other languages?")

1. English/ French {M6l Xl}

2. Local dialect {M6l X2}

3. Other: {M61X3R} {M61X3}

4. Other: {M61X4R} {M6l X4}

5. Other: {M6l X5R} {M61 X5}

MCH client exit inteNiew • 145 62. What is the highest level of school you attended? (Circle one.) {M62}

1 Did not attend formal school 2 Lower primary 3 Upper primary 4 Lower secondary 5 Upper secondary 6 Post-secondary

63. What is your religion? (Circle one.) {M63}

1 Protestant 2 Catholic 3 = Muslim 4 African Spiritual 5 None 6 Other: _ {M63R}

Reproductive health issues

64. To end with, I would like to ask you some questions about other reproductive health issues. I would like to remind you that the information you provide will remain strictly confidential, and that you do not have to answer any question you do not want to. Sometimes a woman can become pregnant when she is not ready to be. In the past, have you ever been pregnant at a time when you were not ready for the pregnancy? {M64}

1 = Yes 2 = No (to q.66) 98 = Don't know / no response (to q.66l

65. (If yes) What did you do the last time this happened to you? (Circle one.) {M65}

1 Nothing, continued with the pregnancy 2 Attempted to stop pregnancy but did not succeed, gave birth 3 Attempted to stop pregnancy and succeeded 4 Other: {M65R} 98 = Don't know

66. As far as you know, are there any diseases that can be transmitted through sexual intercourse? {M66} 1 = Yes 2 = No (to q.691 98 = Don't know / no response (to q.691

67. (If yes) Have you heard or read about some common signs and symptoms of sexually transmitted diseases? {M67} 1 = Yes 2 = No (to q.69) 98 = Don't know (to q.69)

MCH client exit interview • 146 68. (If yes) What are some common signs and symptoms of sexually transmitted diseases? Tick if mentioned (Do not .read list, but probe by asking, "Any other signs or symptoms?")

1. Abnormal vaginal discharge {M68X1 }

2. Abnormal vaginal bleeding {M68X2}

3. Genital itching {M68X3}

4. Lesions / sores {M68X4}

5. Lower abdominal pain {M68X5}

6. Pain during intercourse {M68X6}

7. Painful urination {M68X7}

8. Abnormal growth in genital area (warts) {M68X8}

9. Urethral discharge {M68X9}

10. Los:o \.;f •.••"'ioht {M68X10}

11 . Diarrhoea of long duration {M68X11 } -- .~ 12. Other: {M68X1LR} {M68X12}

69. Have you ever heard of HIV or AIDS, or are you not sure? {M69}

1 = Yes 2 = No (to q.72) 98 = Don't know (to q.72)

70. Have you ever heard of ways that people get HIV/AIDS? {M70}

1 = Yes 2 = No (to q.72) 98 = Don't know (to q.72)

, ....,...".... 71. As far as you know, what are the ways people get \ HIV/AIDS? Tick if mentioned

(Do not read list but probe by asking, IIAny other ways?")

1. Sexual intercourse {M71Xl}

2. Blood transfusion {M71 X2}

3. Sharing items like razor blades or needles {M71 X3}

4. Mother to baby {M71 X4}

5. Other: {M71 X5R} {M71X5}

MCH client exit interview • 147 72. Do you know of any ways you can protect yourself from sexually transmitted diseases including HIV/AIDS? {M72}

1 = Yes 2 = No (to q.74) 98 = Don't know (to q.74)

73. (If yes) What are these ways of protecting yourself? Tick if mentioned (Do not read, but probe by asking, "Any other ways?")

1. Stay faithful to your one spouse/partner {M73X1 } --'.' 2. Encourage spouse/partner to remain faithful {M73X2}

3. Use condoms {M73X3}

4. Avoid sharing needles, razors, etc. {M73X4}

5. Other: {M73X5R} {M73X5}

74. How many sexual partners have you had in the past 12 months? {M74}

_____ partners (If none, to closing)

75. Did you have sex with any new partner(s) in the past 12 months? {M75}

= Yes 2 = No (to closing) 98 = Don't know (to closing)

76. (If yes) Did you use a condom the first time you had sex with your most recent new partner? {M76}

= Yes 2 = No 98 = Don't know

Read closing:

Thank you very much for answering these questions.

MCH client exit interview • 148 MCH client exit interview: those that do not. The clients that do not question-by-question guide find the hours convenient will be asked The client has just finished receiving which hours would be more convenient. MCH services. Be sensitive to the fact that These filter questions always include a "skip the client may have traveled far, waited a pattern" that skips questions that are not ap­ long time for service, and may have been plicable to some clients. Pay careful atten­ through an ordeal. However, she may agree tion to all skip patterns. At the conclusion of to an interview with a sensitive and inter­ the interview, quickly review your coded re­ ested person. (See the section "Tips for con­ sponses for completeness and correctness ducting a good interview" for more and ensure that you followed the correct information, page 23.) skips. If possible, correct any problems Lead the client to a preselected private while the client is still available. place, away from clinic staff and other cli­ ents, and read the greeting. This greeting is 1. What was the main reason you vis­ extremely important because it ensures that ited the facility today? the client has given her "informed consent" Ask the client for the one main reason to be included in the study. Ask if the client she came to the facility today. The client has any questions about the study. If neces­ will have the opportunity later to list all sary, you may provide some simple encour­ the services she received (question 3). agement such as, "Your participation will be greatly appreciated," but in all cases respect 2. Overall, would you say you were sat­ the client's wishes if she does not want to isfied with your visit to the facility be interviewed. If she does not agree to today, or were you dissatisfied with participate, thank her and move on to the your visit today? next client. Clients are frequently reluctant to ex­ You should be able to fill out the informa­ press any overall dissatisfaction because tion on the first page before the interview they wish to be courteous. However, begins. If you are not sure about any of the clients tend to be more expressive of codes, ask your Team Leader. Write (do not dissatisfaction with more specific ques­ sign) your name in the box at the bottom of tions. Questions 4 through 21 of this in­ the page. When you have completed the in­ terview will give the client more terview, your Team Leader will review it and opportunity to specifically critique the sign below your name. For the rest of the in­ services. terview, follow instructions for recording the client's responses by circling a precoded re­ 3. What other health services did you sponse, ticking a box, or writing a response receive today? as instructed. Read each of the services, excluding the Some questions are filters, which means client's response on question 1 as the that they divide some clients from others, in main reason for her visit. Place a tick order to ask them more questions. For ex­ (check mark) in the right column for ample, question 26 divides clients into those each service received. If she received no that find the facility hours convenient and other services, tick 77.

MCH client exit interview: question-by-question guide • 149 4. Do you feel that you received the in­ "Questions" can be on any subject, formation and services that you such as how an infection is transmitted, wanted today? where to get nutrition counseling, etc. Clients come to a facility in order to ob­ Questions can also include "concerns," tain particular information and services. as defined above. The purpose of this question is to find Many dimensions may be considered out if the client obtained the information by the client in answering question 10: and services she desired. for example, the completeness, correct­ ness, or style the provider used in her 5. Do you feel that your consultation responses. Give no assistance in answer­ with the clinical staff was too short, ing this question, because only the cli­ too long, or about the right amount ent can determine her own satisfaction oftime? with the responses to her questions. This information can be compared to the FP clients' satisfaction with the dura­ 11. During this visit, did the provider tion of their consultations. conduct any health examinations or procedures? 6. During this visit, did you have any con­ 12. (If yes) Did the provider explain the cerns about health issues that you examinations or procedures before wanted to discuss with the provider? they were performed? 7. (If yes) Did the provider listen to 13. Did the provider explain the results your concerns to your satisfaction? of the health examinations or proce­ "Concerns" is a broad term. Concerns in­ dures? clude but are not limited to worries or ru­ "Health examinations" include head-to­ mors of health risks, child health, exposure" toe exams, breast exams, pelvic exams, to SID/HN/AIDS, how to maintain pri­ and examinations on any other part of vacy, etc. If the provider reports that she the body. "Procedures" include taking did have concerns, ask question 7. blood pressure or temperature, giving an injection, etc. 8. During this visit, did you have any The idea behind these questions is questions you wanted to ask? that if clients are aware of examinations 9. (If yes) Did the provider let you ask and procedures, they will be more at the questions? ease during their visit. An explanation of 10. (If yes) Did the provider respond to the examination or procedure involves your questions to your satisfaction? telling the client what the provider is Whether clients feel free to ask ques­ about to do, why she is doing it, and tions and whether they are responded what the client can expect to feel. Ex­ to satisfactorily is a strong indicator of plaining the results of the examination quality in interpersonal relations. These or procedure involves telling the client if three questions address the issue of the nurse came to any conclusions or whether the client felt comfortable ask­ diagnosis based on the examination. If a ing for the information she needed. diagnosis is not immediately available,

. MCH client exit interview: question-by-question guide • 150 then explaining the results would in­ 18. If a friend ofyours wanted the ser­ clude telling the client that she will be vices that you came here for today, contacted later about the results. would you encourage her to come to this facility, or would you encourage 14. In your opinion, did you have her to go somewhere else? enough privacy during your consul­ Clients sometimes select a health facility tation with the service provider? based on recommendations from This is the client's opinion, however she friends. This question determines detennines it. whether MCH clients are recommending this facility to friends, which is a proxy 15. During the consultation, did you measure of client satisfaction. feel that the provider was easy to understand when explaining things 19. What did you like most about your to you, or did you feel that the pro­ visit here today? vider was difficult to understand? Emphasize the word "most." Some clients This is the client's opinion, however she may not have liked anything, in which determines it. case you should skip to question 20.

16. About how long did you have to 20. What did you dislike most about wait between the time you first ar­ your visit here today? rived at this facility and the time Emphasize the word "most." Some cli­ you began receiving the services ents may not have disliked anything, or that you came for? may not feel comfortable reporting on The purpose of this question is to deter­ what they disliked. In these cases, leave mine the client waiting time. Encourage the question blank. the client to estimate the time she waited if she does not have a watch 21. Ifyou could suggest one improve­ and/or did not keep track of the time. ment to the services Reserve "don't know" for clients who provided, what would it be? are unable to estimate, even when re­ This important question allows the cli­ quested to do so. ent to mention something that bothered her about the experience, without being 17. Do you feel that the wait between critical. Probe with supportive com­ the time you first arrived at this fa­ ments such as: "Anything at all you cility and the time you began receiv­ would like to suggest is fine." ing the services you came for was reasonable or too long? 22. During this visit, were you given or This is the client's opinion about overall wait­ did you take any brochure or educa­ ing time experienced before she started to tional material to bring home? receive the services she came for. Do not 23. (Ifyes) What was the subject(s) of consider the start of registration proce­ that material? dures as the services she came for. No distinction is made between bro-

MCH client exit interview: question-by-question guide • 151 chures, pamphlets, fliers, or any other tions get at the convenience of the clinic educational material. hours. Even in contexts in which clinic Try to find out the subject matter of hours are set by the Ministry of Health or the brochure or educational material other central authority, information from given to the client. Do not read the list, these questions can be very useful for get­ but probe by asking, "Are there any ting those policies changed if necessary. other subjects?" We are interested in how aware the client is of the material 28. Have you ever been turned away she received. If she would like to refer from this facility during official to her materials and tell you the sub­ working hours? jects, mark her answers. However, if she "Turned away" means refused service, simply shows you the materials, do not or told to come back at another time. look for yourself and mark their sub­ Note that this is about the client's his­ jects, but ask, "What are these about?" tory with the facility (ever), rather than about today's visit. Also, this involves 24. Did you attend a group taIk(s) at the being turned away due to overcrowding facility today? or other unspecified reason. If the client The "group talk" is sometimes called a came once, saw a provider, and was "health talk." It is usually conducted by a told to return for a procedure at a later nurse, and may include many subjects. It date, this does not count as "turned is frequently in the lecture format, but away" for this question. when done well, may include questions, display of samples, or other AV aides. 29. How long did it take you to come "Attend" and "hear" have similar here today? meanings in this question. We are enquiring about the client's travel time from her home, because travel time 25. (If yes) What topics were covered in can sometimes pose a large barrier to the group taIk(s)? services. If the client was coming from Ask this question only if the client at­ work or a relative's house, count the time tended a group talk. We are interested from there. Encourage the client to esti­ in the information that the client remem­ mate the approximate time in minutes. bers during the health talk, so do not prompt her by reading the subject list. 30. What was the main means of trans­ Also note the appropriate probe, "Any port that you used to get here? other subjects?" The client may have used two or three or more forms of transportation-walking 26. Are the hours this facility is open and minibus would be a common combi­ convenient for you? nation. When the client used two or more 27. (If no) What time would be most means of transport, encourage her to de­ convenient to you? cide what she considers her main means. Opening hours of services can be a Any criteria she uses for deciding-time, large barrier to clients and these ques- distance, cost, etc.-is fine.

MCH client exit interview: question-by-question quide • 152 31. As far as you know, what types of 35. In the past 12 months, how many services other than family planning visits have you made to this facility/ are usually provided at this facility? hospital for (various services)? This question addresses clients' aware­ 36. In the past 12 months, how many ness of other services, which will later visits have you made to any other fa­ be compared to the actual services cility/hospital for (various services)? available. This gives an idea whether These questions assess the level of utili­ some services are underutilized because zation of services among MCH clients, people are simply not aware of them. both at this facility and elsewhere. Remember that the client will not use our exact terms. Interpret her comments 37. Now I would like to ask you about into the categories to the best of your the cost oftravel and services that ability. If the client says "STD," or "HIV," you have received from this clinic. you may probe with "What kind of STD How much did you pay for (various or HIV services are usually provided?" in services and travel)? order to come closer to the coding cat­ Clients may know the total amount paid egories available. without knowing how the charges were divided. If this is the case, make a note 32. Apart from this facility, is there any in the margin with the total amount. other place near your home where you can go for the services that you 38. Overall, do you feel that the total came here for today? cost of obtaining services is much 33. (Ifyes) What type offacility is it? too expensive, a little too expensive, 34. What would you say is the main or acceptable to you? reason you did not go there for the Because the burden of expenses can only services? be judged relative to a client's income, this A client's choice of facilities is important question gives the client the chance to as­ because it may have been motivated by sess the difficulty she has in paying for the quality of services she experiences. services, even if the cost is quite low. These three questions address those cli­ ents who have decided to come to this 39. Now I would like to ask you some facility rather than another. questions about having children. Do Ifthe client indicates there is another fa­ you know of any ways or methods cility close to her home or workplace, or an­ that women and men can use to de­ other place she regularly visits, code lay or prevent a pregnancy? question 32 accordingly. Then questions 33 40. (Ifyes) Please tell me any such and 34 should be asked, and the client methods that you know of. should be encouraged to think about only These questions assess the family plan­ one other facility, the one closest to her ning knowledge of MCH clients. If the home or workplace. In question 34, the cli­ client has heard of some methods, ask ent may mention more than one reason. En­ question 40 but do not read the list of courage her to decide on one main reason. methods. Let the client tell you all the

MCH client exit interview: question-by-question guide • 153 methods she can spontaneously men­ results from this question can inform tion. Probe by asking "Any other meth­ managers about how receptive the MCR ods?" Be aware that the client may not client population is to FP messages. use the terms on the list of methods. Classify as well as you can what the cli­ 45. Are you or your spouse/partner cur­ ent says, using our terms. rently using any method to space, avoid, or prevent a pregnancy? 41. (If mentioned) As far as you know, 46. (If yes) Which method? is it possible to obtain this method These results can be compared to the FP at this health facility? results for type of method used. Meth­ For each method that the client men­ ods used by husband/partner(s) such as tions, ask her if the method can be ob­ condoms, vasectomy, and withdrawal tained at this facility. This information are attributed to the client as well. will be checked against the actual avail­ ability of the method at this facility, 47. Where do/did you go to get your which will give managers an idea of current family planning method? how well-known their services are. 48. What is the main reason you obtain your method from that place and 42. Did you hear or see anything about not somewhere else? family planning in this health facil­ These questions about contraceptive ity today? supply give important information about 43. (If yes) Did you (see poster/see the FP outlets that are used by women pamphlet/attend health talk/etc.)? who may not come to this facility for FP Although much of the Situation Analysis services. If their responses to question is concerned with how RH services are 48 show, for example, that they feel the integrated into FP services, these two quality of services is better elsewhere, questions assess whether FP is inte­ then the manager will have identified an grated into MCH services. important problem.

44. Do you yourself approve or disap­ 49. Now, I would like to ask you a few prove of couples using a method of questions about yourself. Are you family planning to avoid getting currently breastfeeding? pregnant? 50. (If yes) Are you breastfeeding exclu­ This attitudinal question is an important sively, nearly exclusively, or supple­ proxy for the acceptability of FP in the mented regularly with food and/or general population. Presumably, all FP liquids? clients approve of FP use, so their atti­ If the client is breastfeeding during the tudes on FP are not representative of interview, do not ask the question but the general population. MCH clients, al­ simply code "yes" on question 49. though also not strictly representative of For question 50, "exclusive the general population, can give a better breastfeeding" means only breast milk idea of more general attitudes. Also, the and nothing else; no water, juice, or

MCH client exit interview: question-by-question guide • 154 other foods. "Nearly exclusively" means 56. How many living children ofyour primarily breast milk but sometimes own do you have? some water or juice. "Supplemented Emphasize the words "living" and "your regularly" means breast milk with other own." This question is intended to deter­ liquids and foods also given. Try to de­ mine the number of children to whom termine which of these categories is the woman has given birth. It excludes closest to the current breastfeeding be­ adopted children and children of other havior of the client. relatives presently living with her.

51. How old are you? 57. What is the age ofyouryoungest child? Write the number of years mentioned by Note that the age of the youngest child the client. If she doesn't know her age should be recorded in months. exactly, try to help her estimate with some important historical dates as benchmarks 58. Would you like to have any (more) as instructed in training. If she has no children? idea what her age is, write 98. Ask "any" with a client who has no chil­ dren. Ask "any more" with a client who 52. What is your current marital status? has one or more children. This question should be answered using the client's definition of marriage. 59. (If yes) When would you like (a) (the next) child? 53. (If not married) Do you have a regu­ Ask "a" with a client who has no chil­ lar partner? dren. Ask "the next" with a client who A regular partner is someone with whom has one or more children. the client has sexual intercourse on a regular basis, independent of the frequency. 60. Can you read and understand a let­ ter or a newspaper easily, with diffi­ 54. Have you ever discussed family culty, or not at all? planning with your husband or 61. Which languages can you read and regular partner? understand? 55. Do you think your spouse/partner 62. What is the highest level of school approves or disapproves ofyour us­ you attended? ing a method to space or avoid a 63. What is your religion? pregnancy? These four questions address the gen­ Discussion of family planning within eral socio-economic status of the clients. couples is a possible factor affecting fam­ This can be used in designing programs, ily planning use and continuation. These producing appropriate lEe materials, questions get at the amount of discussion and arranging services in socially and and approval of FP that takes place culturally acceptable ways. among couples that may not be using In question 62, note that we are en­ FP at the moment. This can be compared quiring about "attended"-not necessar­ to similar results for the FP clients. ily"completed."

MCH client exit interview: question-by-question guide • 155 64. To end with, I would like to ask you 70. Have you ever heard ofways that some questions about other repro­ people get HIV/ AIDS? ductive health issues. I would like to 71. As far as you know, what are the remind you that the information you ways to get HIV/ AIDS? provide will remain strictly confi­ Be aware that the client may not use our dential, and that you do not have to terms when describing transmission answer any question you do not want routes. Classify as well as you can what to. Sometimes a woman can become the client says, using our terms. pregnant when she is not ready to be. In the past, have you ever been preg­ 72. Do you know of any ways you can nant at a time when you were not protect yourself from sexually trans­ ready for the pregnancy? mitted diseases including HIV/ 65. (If yes) What did you do the last AIDS? time this happened to you? 73. (If yes) What are these ways ofpro­ These questions are sensitive, but are tecting yourself? usually answered when the interviewer These knowledge questions are ex­ has developed a rapport with the client, tremely important. Note that although and is straightforward and nonjudg­ HIV/ AIDS is itself a sexually transmitted mental. For this reason, these questions disease, clients (and providers) may of­ have been placed at the end of the in­ ten think of it as a separate and distinct terview, after the client is used to being category. asked questions. 74. How many sexual partners have you 66. As far as you know, are there any had in the past 12 months? diseases that can be transmitted Write the number of partners the client through sexual intercourse? mentions. If she says none, end the in­ 67. (Ifyes) Have you heard or read about terview by thanking the client for her some common signs and symptoms of time and assistance. sexually transmitted diseases? 68. (If yes) What are some common 75. Did you have sex with any new signs and symptoms of sexually partner(s) in the past 12 months? transmitted diseases? 76. (If yes) Did you use a condom the Be aware that the client may not use our first time you had sex with your terms when describing symptoms. Clas­ most recent new partner? sify as well as you can what the client These questions address the amount of says, using our terms. risk clients are generally exposed to. In question 76, emphasize that we are ask­ 69. Have you ever heard of HIV or AIDS, ing about the first time you had sex with or are you not sure? your most recent new partner.

MCH client exit interview: question-by-question guide • 156 Chapter 4

Data analysis and reporting

Data entry and cleaning The questionnaires in this book have sug­ Once the data collection is complete, then gested variable names, presented in brackets the data must be entered into a computer in { }, for each question or tick mark. All five preparation for the analysis. The completed questionnaires share some identifying vari­ questionnaires should be gathered in one ables on the opening pages, such as health central location and ordered by date of visit, facility code, district code, type of SDP, sec­ district, or any other criteria. After they are tor, etc. These variables are given intuitive ordered, the questionnaire numbers should names such as {DISTCODE}, {DATE} or be filled in for each instrument in the upper {TYPE}. Moreover, each questionnaire has an righthand corner. These numbers should be­ identifying variable, called {lID}, {OlD}, {FID}, gin with 1 for each instrument, and will be {SID}, and {MID}, to represent identifying used to identify individual questionnaires. variables from the inventory, observation, FP This process is crucial to the data cleaning client exit interview, staff interview, and and analysis. MCH client interview, respectively. These Depending on the size of the SA, data en­ variables hold the questionnaire numbers try can take from two to six weeks. Sometimes described above. investigators hire members of the data collec­ The rest of the variable names in each in­ tion team to stay on and perform the data en­ strument follow a simple pattern. They all try, which requires a certain familiarity with begin with a letter: "I" for inventory, "0" for computers. The data entry is usually done us­ observation, "F" for FP exit interview, "s" for ing Epi Info, since the data entry process is staff interview, or "M" for MCH exit inter­ fairly simple and the software is free. 1 view, to identify the module. Next comes the Once in the computer, the data will con­ question number, which ranges from 1 to tain a variable for each question or tick over 100 in the FP exit interview. If the mark on the questionnaires. Each of these variables will have a different name that can 1 Epi Info is a DOS-based epidemiological package that allows for questionnaire design, data entry, be used in the analysis. For example, the and data analysis, developed by the Centers for variable corresponding to the first question Disease Control. It is available free from the Divi­ in the staff interview might be called "S1." sion of Surveillance and Epidemiology, Epidemiol­ The assignment of variable names is entirely ogy Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, 30033 U.S.A., up to the researcher-any name will do as telephone (404) 728-0545. It can also be down­ long as it is unique, and understandable to loaded from the CDC's World Wide Web page at the people who will be using the data. www.cdc.gov.

Data analysis and reporting • 157 question has several parts to it, such as sev­ variable names are systematically based on eral lines in a table that can each be ticked the question number, such as "F4Xl," then off separately, then each part is considered the user can find the variable name simply one "extension" of that question. Extensions by looking at the question, and find the are marked with an "X" and an extension question simply by looking at the variable number. For example, question 4 of the FP name. This is extremely valuable and time­ client interview asks about the other ser­ saving in analysis. vices the client received at the SDP. There Once all the data is entered, it must be are sixteen other services listed, and each cleaned. There are two basic kinds of clean­ can be checked off individually, so they ing that should always take place before any each need a separate variable name. These analysis: variables are named: "F4Xl," "F4X2," "F4X3," and so on to "F4XI6."2 In this way, the name • Check for wildcodes of each variable gives the researcher infor­ A "wildcode" is a value of a variable mation on which questionnaire it is from, that has no meaning. For example, the which question it addresses, and which part question might be "Did you accept FP of the question it concerns. today?" and the responses are "1=no" Some of the questions have lists of pos­ and "2=yes" for 100 clients. After data sible answers, as in the above example, and entry, the frequency for this variable a space for "Other: ." In these cases, the shows 75 cases as "1," 24 cases as "2," interviewer writes in the specific category and one case as "3." Since "3" is not a and ticks it. This written information about possible answer for this question, it "other" must also be recorded in the data, must have been a mistake in data entry. and needs a separate string variable. These This is called a "wildcode." This can be variables are named with an "R" at the end, cleaned by looking at the ID variable to stand for other.3 In question 4 of the FP for that case (lID, OlD, FID, SID, or exit interview, for example, the last exten- MID), using that to find the original sion is "Other: ," and the interviewer questionnaire, and checking the ques­ ticks whether this "other" service was re­ tion of interest. Usually, the correct an­ ceived. The variable name for the tick mark swer is available this way, and the case is "F4XI6," and the variable name for the in­ can be recoded to a "1" or "2." formation written on the line is "F4XI6R." This suggested variable naming system might seem complex at first, but of the 2 Note that the "X" is a crucial part of the variable many systems that have been attempted name and should not be deleted. If the "X" were removed from these variable names, they would with SA studies, this has proven to be the become "F41," and "F42," and so on. This is a prob­ easiest system to use by far. If variable lem because these names cannot be distinguished names are created from shorthand English from the names for the forty-first and forty-second based on the content of the question, such question of the interview. 3 It might have been more intuitive to use "0" for as "OTHSVCl," the user quickly finds that Other, but an "0" is very easily confused with a the variable names become awkward, zero, and the variable names become quite difficult unintuitive, and not unique. If, however, the with that approach.

Data analysis and reporting • 158 This first step, then, is to look at the tion, and 35 answer the second ques­ frequencies of all the variables and tion, then the data are internally incon­ check them against the questionnaires sistent. The original questionnaires for wildcodes. If for some reason the should be checked. original questionnaires are not avail­ This consistency check is extremely able or the data for that question is important in the FP exit interview. First, missing, then the wildcodes should be all clients are asked several questions set to "9" or some other code that together, and then a filter question di­ means "missing data." vides them into new and revisit clients, who receive specific questions. The cli­ • Check internal consistency ents are then divided further into vari­ A "filter question" selects certain ous method users, and asked another people to be asked some follow-up set of specific questions. For this rea­ questions. A simple filter question is: son, it is important to check all the in­ "Do you want more children?" with re­ ternal consistencies in this module in sponses "yes" or "no." If the client an­ particular. swers "yes," then she is asked, "When If data is entered in Epi Info, it is possible do you want more children?" If 25 of to create automatic checks that prohibit data 100 people answer "yes" to the first entry clerks from entering wildcodes or in­ question, then 25 people should have a ternal inconsistencies by misktake. For more response for the second question. If 25 information, refer to the Epi Info manual on people answer "yes" to the first ques- creating .CHK files.

Data analysis and reporting • 159 Analysis plan

The primary results from most SA studies are sis, but the first step is a simple presentation presented in a report that gives as much rel­ of results. Over the years, these primary re­ evant, simple, descriptive information about ports have developed a fairly standard struc­ the program as possible. Later, the data ture. Table 1 gives a typical outline for an SA might be used for fl,lrther secondary analy- report.

TABLE 1. Typical outline for Situation Analysis primary report

I. Introduction A. History of FP program in country/region B. Principal agencies in SA study C. Justification of the SA study D. Objectives of SA study II. StUdy methodology A. Sampling method B. Implementation i. Revision of questionnaires ii. Training of data collectors iii. Data collection process iv. Cleaning and inputting of data C. Data analysis and utilization i. Analysis of data ii. Diffusion of results III. Results A. Description of samples B. Readiness to provide services i. Services provided ii. Infrastructure, facilities, and equipment iii. Staff experience and training iv. IEC materials and activities v. Supplies and logistics vi. Recordkeeping, reporting, and supervision C. Quality of services i. Interpersonal relations ii. Choice of methods iii. Information exchange iv. Technical competence v. Mechanisms to encourage continuity vi. Appropriateness and acceptability of services IV. Recommendations for action

Appendix 1: List of all participants/data collectors

Appendix 2: Instruments

Analysis plan • 160 The following analysis plan deals with the The amount of information collected in "Results" portion of the outline in Table 1. It one SA can be overwhelming. This analysis arranges the information collected by the SA plan includes information from virtually ev­ instruments into three areas: description of ery variable in all five SA instruments, result­ samples, readiness to provide services, and ing in over 130 indicators. However, no quality of care. The latter two parts are fur­ written analysis has ever used all the indica­ ther divided into sub-elements. The informa­ tors listed. Instead, researchers and program tion under "Readiness to provide services" is managers select the set of indicators they arranged by: services provided, infrastructure, feel to be most important for their program, staff, lEe materials, supplies, recordkeeping, and report on only those. The indicators that and supervision. The information under "Qual­ are most frequently used and that seem to ity of care" is arranged according to the Bruce/ be the most informative about program Jain framework described in Chapter 1: inter­ functioning are marked with a check (,/) personal relations, choice of methods, infor­ next to the indicator name. mation exchange, technical competence, The analysis plan also includes informa­ mechanisms to encourage continuity, and the tion on how to calculate the indicators. The appropriateness and acceptability of services. three central columns in the table direct the The·information under each of these head­ user to the instrument, question, and vari­ ings is presented as a list of indicators. Each ables that supply the information for each indicator specifies a distribution, percentage, indicator. The rightmost column gives com­ or mean of some result, which can be used as ments on how the indicator is normally cal­ an indication of the quality of services. Some culated and presented. Note that for of these indicators are quite simple and particularly difficult or complex calculations, straightforward, but others require substantial more detailed comments are given at the calculation involving many variables. end of the table.

Analysis plan • 161 Analysis Plan: Description of samples

Result Instr. Question Variables Comments V = frequently used indicator numbers

1. Number of SOPs visited and n for V- Ail - - This is the total n from each dataset. each instrument Often presented by district as well.

2. Distribution of SOPs by type V- I Cover page TYPE Do not use TYPE, SECT, or LOC variables from any instrument other 3. Distribution of SOPs by sector V- I Cover page SECT than the inventory. 4. Distribution of SOPs by locality V- I Cover page LOC

5. Distribution of FP clients, by type V- 0 Page 2 PURPOSE Present as a pie chart.

6. Sociodemographic characteristics of V- F 103,104, F1 03, F1 04, These include: age, marital status, FP and MCH clients 105,112, F1 05, F112, literacy, languages spoken, educational ~ Dl 113,114, F113X1 to F113X5, level, and religion. ~ 115 F114,F115 iii" "C Usually, results for FP and MCH clients iii ::l M 51,52,53, M51, M52, are presented as two columns in a .... 60,61,62, M53, M60, table. ~ 63 M61X1 to M61X5, M62, M63

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Result Instr. Question Variables Comments V' = frequently used indicator numbers

7. Reproductive status and sexual V' F 101,102, F1 01 ,F1 02,F1 08, These include: number of children, age history of FP and MCH clients 108,110, F1 09,F11 0,F111, of youngest child, breastfeeding status, 110,111, F116,F117F124, reproductive intentions, number of 116,117, F125,F126 partners in last year, any new partners 124,125, in last year, whether used condom with 126 new partner, and abortion history.

M 49,50,56, M49,M50,M56, 57,58,59, M57,M58,M59, 64,65,74, M64,M65,M74, 75,76 M75,M76

8. Contraceptive background of FP and V' F 43,44,62, F43, These include: MCH clients 106,107 F44X1 to F44X98, For all clients: ever discuss FP with » ::::J III F62,F1 06,F1 07 partner, whether partner knows of ~ FP use. iii" "2- For MCH clients: knowledge of and ~ M 39,40,44, M39, attitude toward FP, current use. ....• 45,46,54, M40X1 to M40X13, For new FP clients: ever use of FP . OJ U) 55 M44,M45,M46, For revisit FP clients: reason for M54,M55 wanting to stop or switch.

9. 50ciodemographic characteristics of V' 5 32,33,34, 532,533,534, These include: age, marital status, providers 35,36 535,536 number of children, gender, and religion

10. Current use of FP by providers 5 37 537X1 to 537X77 Present as pie chart. Include "none" as part of chart.

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Analysis plan: Readiness to provide services

Readiness indicator Instr. Question Variables Comments V' = frequently used indicator numbers - I Services provided I 11 . Percent of SDPs that usually offer V' I 18,21 118X1 to 118X9 Present as a bar chart by method. FP methods 121X1 to 121X6

12. Percent of SDPs that usually offer V' I 8 18A2 to 18A 17 Present as a bar chart by service. other services, either in FP unit or 1882 to 18817 elsewhere in facility

13. Mean and median number of new V' I 36,37 136A1 to 136A7 If data are supplied for less than a year, and revisit clients in a year, by 13681 to 13687 create an annual estimate by taking a monthly type of service 136C1 to 136C7 average (based on column C), and multiplying 137X1,I37X2 by 12. Use q. 37 to check the recency of the >::J ~ information. iii" "'C 14. Distribution of SDPs by FP client V' I 36 136A1 Divide the SDPs into quartiles by client load ~ load 13681 and report the percentage of the total client ....• 136C1 load per quartile.' m .j>. 15. Number of days per week FP V' I 6 16 Present as a mean and/or a pie chart. services are offered

16. Distribution of MCH clients among M 1 M1 This gives an idea of the relative importance other services of other services to the program.

17. MCH client service utilization, at M 35,36 M35X1 to M35X4 Present as a bar chart with two series: one this clinic and others M36X1 to M36X4 for this clinic, and one for other SDPs.

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Readiness indicator Instr. Question Variables Comments V" = frequently used indicator numbers

18. Percent of SDPs that offer tests I 22,23 122 Note that "providing" a test means at the for pregnancy and specific 123A1 to 123A7 SDP itself or through referral. Present as a bar diseases 12381 to 12387 chart by test. Use q. 22 as a filter.

19. Percent of SDPs that usually offer I 24 124Xl to 124X6 Present as a bar chart. specific immunizations

20. Percent of providers reporting that S 30 S30 These questions give a general idea of clients seek abortion advice at abortion demand in the area. They are their SDP suggestive only, since the providers may not see a representative sample of abortion 21. Percent of providers reporting that S 31 S31 patients. Also, heavy reporting biases affect clients seek post-abortion care at these questions, particularly in countries their SDP where abortion is illegal.

>::J III Infrastructure, facilities, and equipment ~ iii "0 22. Percent of SDPs with working V" I § 9 19X1 to 19X6 This includes water, electricity, toilets, and necessary infrastructure seating. Present as a bar chart. .... 0> t11 23. Percent of SDPs with appropriate V" I 15 115Xl to 115X5 This includes: auditory privacy, visual privacy, examination areas cleanliness, adequate light, and adequate water. Present as a bar chart.

24. Percent of SDPs missing selected V" I 16,17 116Xl to 116X18 Of the many pieces of equipment listed, FP equipment 117Xl to 117X6 select the ones program managers find most important. Note that this indicator calls for the reverse of the data: if 85 % of SDPs have a sterilizer, then report here that 15% are missing a sterilizer. On the items that are counted, set an appropriate threshold for the number of items an SDP should have in order to be properly equipped. Then report on the SDPs that have fewer than the threshold.

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Readiness indicator Instr. Question Variables Comments V' = frequently used indicator numbers I5taff experience and training I 25. Distribution of providers by type I 10 110X1 to 110X7 Present as a pie chart. Do not use the staff types from the staff interview module, but only from the inventory.

26. Distribution of providers on duty I 11 111 x 1 to 111 X7 Compare to total staff in indicator 25. today by type

27. Percent of staff whose basic V' 5 4 54X1 to 54X12 Present as bar chart by subject. Can present training included various issues by type of provider as well.

28. Mean and median years since V' 5 3 53 Can present by type of provider if there is a basic training large difference. » :l, 29. Percent of providers whose post- V' 5 6,7 56, Present as a bar chart by subject. Can report ~ basic/refresher training included 57X1 to 57X19 among all staff, or use q.6 as a filter and iii "'C specific FP/5TD issues report only among staff that have had this ~ training...... 0>, 30. Mean and median years since 5 8 58X1 to 58X19 Compute this by topic, among those staff 0>, post-basic/refresher training in reporting on q.8. Note that the n will change FP/5TD issues for each topic.

31. Percent of providers who have had V' 5 5 55X2 to 55X12 Present as a bar chart. refresher training in other health issues

32. Mean and median years providers 5 2 52 Can present by type of staff if there is a large have been working at their facility difference.

33. Percent of providers actively 5 1 51 X 1 to 51 X 18 Present as a bar chart. providing various services at this 5DP

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Readiness indicator Instr. Question Variables Comments I/' = frequently used indicator numbers

34. Percent of providers providing I/' S 9,10 S9 Present as a bar chart. Usually calculated various FP methods in last 3 S10X1 to S10X15 among all staff; do not use q. 9 as a filter. months IIEC materials and activities I 35. Percent of SOPs with a sign I 7 17 Present as a pie chart. announcing FP services

36. Percent of SOPs with various IEC V I 12 11 2A1 to 11 2A7 Present as a table or bar chart with the IEC materials available 112B1tol12B7 items on the x-axis and a different bar for 112C1 to 112C7 each subject.

37. Percent of SOPs that offer health I/' 1 13 113 ,.. talks ::J ~ 38. Percent of health talks that include I/' I 14 114X1 to 114X15 Present as bar chart. Use q.13 as a filter. (jj various subjects "0lilr======~ ISupplies and logistics I ..... 0> ..... 39. Percent of SOPs experiencing I/' I 18,19, 118X1 to 118X9 If the SOP has had a stockout in the last six stockouts of contraceptive 20 119X1tol19X9 months (q.201 or has no supplies today supplies in the previous six 120X1 to 120X9 (q.19), count it as having had a stockout. months Use q.18 as a filter - do not include in the denominator SOPs that do not offer the particular method. The n will change for each method.

40. Percent of SOPs with appropriate I/' I 29 129X1 to 129X4 Present as a bar chart by commodity. stocking conditions for commodities

41. Percent of SOPs that store stocks I/' I 28 128X1 to 128X4 Present as a bar chart by commodity. by expiration date

I =Inventory 0 =ObseNation guide F =FP exit inteNiew S =Staff inteNiew M =MCH exit inteNiew Readiness indicator Instr. Question Variables Comments V- = frequently used indicator numbers

42. Percent of SOPs with supply I 26,27 126X1 to 126X4 Present as a pie chart with three slices: SOPs inventories 127X1 to 127X4 with no inventory, those with an inventory in good condition, and those with an inventory not in good condition.

43. Percent of SOPs that have I 24,25 124X1 to 124X6 Present as bar chart by commodity. Use q.24 experienced a stockout of 125X1 to 125X6 as a filter - do not include in the denominator immunization supplies in last 6 SOPs that do not offer the particular months immunization. The n will change for each immunization.

Recordkeeping, reporting, and supervision

44. Percent of SOPs with client record V- I 30 130 Present as a pie chart. card systems :J> t. 45. Of those SOPs with client record V- I 30,31 130,131 Present as a pie chart. Use q.30 as a filter. Ul "0 card systems, percent with cards § in good condition • ...... 0>

47. Percent of SOPs that send I 33 133X1 to 133X3 Present as a bar chart by type of service. statistical reports to higher units

48. Percent of SOPs that have V- I 34 134 Programs often establish norms for the received at least one supervisory frequency of supervisory visits. The wording visit in the previous six months of this indicator can be changed to test if those program norms are being met. Instead

of IIat least one, II this could read "two or more," etc.

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Readiness indicator Instr. Question Variables Comments V = frequently used indicator numbers

49. Among SOPs that have received a V I 34 134 Average only among those that list 1 or more supervisory visit in the previous on q.34. six months, mean number of visits per SOP

50. Percent of supervisors performing V I 34,35 134 Note the reduced n - use only those SOPs various activities 135X1 to 135X7 that have had at least one supervisory visit. Present as a bar chart.

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview

::l»- at '(;i Iii" "2­ ll> ::l .... $ Analysis plan: Quality of care

Quality indicator Instr. Question Variables Comments II' = frequently used indicator numbers IInterpersonal relations I 51. Percent of FP clients who received II' 0 1 01 a friendly greeting

52. Percent of FP clients who feel that II' F 7,8 F7,F8 Report either among all clients or among the provider listened to her those who had concerns. concerns

53. Percent of FP clients who a) had II' F 9,10,11 F9,F10,F11 Note reduced n for each part of this indicator. questions, b) provider let ask the This is sometimes reported for new clients question, and c) were satisfied only. s- with answer III These results can also be compared to MCH ~ iii clients (MCH interview q.8,9, 10). 'C iii" ::J 54. Percent of providers who are S 29 529 Present as a pie chart. ... comfortable discussing HIV/STDs Cl 55. Percent of FP clients reporting that II' F 12,13, F12,F13,F14 Use q 12 as a filter to reduce to only those physical examinations were 14 clients who had a physical examination. explained beforehand and afterward These results can also be compared to MCH clients (MCH interview q.11, 12,13). IChoice of methods I 56. Percent of new FP clients who II' 0 12 012X1 to 012X13 Present as a bar chart by method. were told about various methods

57. Mean number of methods II' 0 12 012X1 to 012X13 mentioned to new FP clients

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V- = frequently used indicator numbers

58. Percent of new FP clients and F 48,68 F48,F68 Combine new clients and revisit clients who switching revisit clients who are switching methods. report that they heard about more than one method from the provider

59. Percent of new FP clients asked if V- 0 10 010 they have a preference for a method

60. Percent of providers who 0 15 015 encourage one method over others during the consultation

61. Percent of providers who report V- S 11,12, S11X1toS11X5 These barriers are: age, marital status, parity, > that they impose barriers on 13,14, S12X1 to S12X5 spousal consent. These indicators take ::::l 2 III methods 15,16, S13X1 to S 13X5 substantial calculation. Present as a table, ~ Ul 17,18 S14X1 to S14X5 by method. '0 Sl S15X1 to S15X5 ::::l ... S16X1 to S16X5 "j S17X1 to S17X5 S18X1 to S18X5

62. Of providers imposing barriers, V- S 11,12, S11X1 to S11X5 These indicators take substantial calculation. 2 mean minimum age, maximum 13,14, S12X1 to S12X5 Present as a table, by method. age, and parity required, by 15,16 S13X1 to S13X5 method S14X1 to S14X5 S15X1 to S15X5 S16X1 to S16X5

63. Percent of providers who would S 19,19a, S19,S20 Present as a bar chart by method. Use two recommend various methods for 20,20a S19AX1 to S19AX13 bars per method: one for recommendations spacing/limiting clients S20AX1 to S20AX13 for spacing clients, the other for recommendations for limiting clients.

I = Inventory 0 = Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V' = frequently used indicator numbers

64. Percent of providers who report V' 5 22,22a 522 that they would never recommend 522AX1 to 522AX13 certain methods

65. Percent of FP clients whose 0 26 026 Note that these two indicators measure very chosen method was the same similar outcomes, but one is from the they expressed a preference for observation and the other is from the client exit interview. 66. Percent of new FP clients who V' F 48 F48 report that they received their method of choice

67. Of those new FP clients that did F 51,52 F51,F52 Present as a pie chart. Use q.51 as a filter. not receive their method of choice, preferred method ::>» III ~ 68. Of those FP clients whose chosen 0 26,27 026,027 Note that these two indicators measure very iii "'C method was not their preferred similar outcomes, but one is from the iii" ::> method, observed reason observation and the other is from the client .... exit interview. fj 69. Of those new FP clients that did F 51,53 F51, not receive their method of F53X1 to F53X98 Use q. 26 and q.51 as filters. choice, reported reason

70. Of new FP clients who decide not 0 21,22 021,022 Present as pie charts. Use q. 21 and q.45 as to use FP, reasons filters. The comparison between the observation and exit interview information F 45,46 F45,F46 gives an idea of how these decisions are percieved by clients vs. providers.

71. Of revisit FP clients who want to 0 23,24 023,024 Present as a pie chart. Use q.23 as a filter. stop or switch, reasons for stop or switch

I = Inventory 0 = Observation guide F = FP exit interview S = Staff interview M = MCH exit interview Quality indicator Instr. Question Variables Comments ..... = frequently used indicator numbers I Information exchange I 72. Percent of FP clients with whom ..... 0 2,5,7 02X1 to 02X77, Separate new and revisit clients, since a more various FP issues were discussed 05,07 complete discussion is usually required for new clients. Note that q.5 is only for new clients, q.7 is only for revisits.

73. Percent of FP clients who received ..... 0 13 013X1 to 013X77 This can be calculated among new users and information on the method revisit clients who are switching to a new accepted method. Present as a bar chart by type of information.

74. Percent of new FP clients and F 49,69 F49,F69 Combine new clients and revisit clients who switching revisit clients who are switching methods. 5- report that they were told they ll> could change methods if they are ~ en not happy with their new method 'C iii ~ 75. Percent of FP clients with whom ..... 0 20 020X1 to 020X77 Present as a bar chart by subject. This is

~ other health services are sometimes reported among new and revisit (j discussed clients separately.

76. Percent of FP clients with whom ..... 0 16 016X1 to 016X77 Calculate this only among SDPs with IEC IEC materials were used (at SDPs materials, so that the indicator measures the with IEC materials available) use of IEC materials rather than their I 12 11 2A1 to 11 2A7 presence, which is measured in indicator 36. 11281 to 11287 This requires linking the observation data with the inventory.3 112C1 to 112C7

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments II' = frequently used indicator numbers

77. Percent of FP clients given F 18,19 F18, Calculate this only among SOPs with brochures on various issues (at F19X1 to F19X98 brochures available, so that the indicator SOPs with brochures available) measures the distribution of IEC materials rather than their presence, which is measured in indicator 36. This requires linking the I 12 11281 to 11287 observation data with the inventory.3

These results can also be compared to MCH clients (MCH interview q.22,23).

78. Percent of FP clients who were II' 0 17 017 told that condoms prevent STOs

79. Percent of LAM clients given 0 14,25 025 Calculate only among LAM clients. Use q.25

;j» proper information on the method 014X1 to 014X77 as a filter. % iii" 80. Percent of FP clients that attended F 20 F20 These results can also be compared to MCH "0 ~ a group talk clients (MCH interview q.24). ... 81. Percent of FP clients who report F 21 F21 X 1 to F21 X98 Present as a bar chart. If the FP exit ~ hearing about various subjects in interview is linked to the inventory,3 then you group talks can compare what was told to clients in these health talks with what they retain. See indicator 37.

These results can also be compared to MCH clients (MCH interview q.25).

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V' = frequently used indicator numbers

82. Percent of FP clients who are V' F pill: F72, F73, F74,F75 These indicators can be reported as a group knowledgeable about their method 72-77 F76X1 to F76X98 of individual items that clients are aware of, F77X1 to F77X98 or they can be combined into knowledge scores. 4 The results are usually reported by IUD: F82 method, but they can be reported overall as 82-87 F83X1 to F83X98, well. F84 F85X1 to F85X98, F86,F87

inj: F92, 92-95 F93X1 to F93X98 F94X1 to F94X98 F95 ?; !!!. 83. Percent of FP clients who are F 118,119 F118 These indicators can be reported as a group ~ iii" knowledgeable about STDs/HIV F119X1 to F119X98 of individual items that clients are aware of, "2­ III symptoms or they can be combined into knowledge :J 4 scores • .... 84. Percent of FP clients who are F 120,121 F120 OJ knowledgeable about routes of F121X1 to F121X98 These results can also be compared to MCH HIV transmission clients (MCH interview q.66-73l. 85. Percent of FP clients who are V' F 122,123 F122 knowledgeable about protection F123X1 to F123X98 against STDs/HIV

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V" = frequently used indicator numbers

86. Percent of FP clients who know of F 30 F30X1 to F30X98 If the FP exit interview is linked to the other services at this facility inventory,3 then you can compare what services are actually available with the services clients are aware of (see indicator 12), You may find that clients are not aware of services that are available, or they may be I 8 18A1 to 18A 17 under the impression that services are 1881 to 18817 available that actually are not.

These results can also be compared to MCH clients (MCH interview q.31).

87. Among revisit FP clients who F 62,63 F62,F63 This indicator addresses the relationship experienced side effects with their between continuity of use and receiving ~ III methods, percent who had been information on side effects. The results may ~ told about side effects when they show that those who want to switch or stop Iii" '0 first received method due to side effects may not have been til ;j properly informed of them at the outset. ...• However, the results are suggestive only, ~ since clients who stop often do not come back to the SDP, so they are not included in the indicator.

88. Percent of MCH clients aware of M 41 M41 X 1 to M41 X 13 If the FP exit interview is linked to the methods available at this SDP inventory,3 then you can compare the methods that are actually available with those MCH clients are aware of (see indicator 11).

89. Percent of MCH clients who saw M 42,43 M42, information on FP during visit M43X1 to M43X5

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V = frequently used indicator numbers ITechnical competence I 90. Percent of FP clients clinically V 0 3,4 03X1,03X2 FP program policies often specify which assessed for FP 04X1 to 04X7 assessments should be carried out on clients. Refer to these standards when selecting items to include in this indicator.

Present as a bar chart. This is usually reported separately among new and revisit clients.

91. Percent of pelvic exams during V 0 37,38 037X1 to 037X77 Present as a bar chart for the 9 actions listed. which providers performed various 038X1 to 038X77 Note that the unit of analysis is the pelvic actions exam, not the provider or client. 5- ll> 92. Percent of IUD insertions during V 0 39 039X1 to 039X77 Present as a bar chart for the 4 actions listed. ~ 1ij" which providers performed various Note that the unit of analysis is the IUD "Q. ll> actions insertion, not the provider or client. ::::l

~ 93. Percent of injections during which V 0 40 040X1 to 040X77 Present as a bar chart for the 3 actions listed. :::J providers performed various Note that the unit of analysis is the injection, actions not the provider or client.

94. Percent of NORPLANT® insertions V 0 41 041X1 to 041X77 Present as a bar chart for the 4 actions listed. during which providers performed Note that the unit of analysis is the various actions NORPLANT® insertion, not the provider or client.

95. Percent of procedures during V 0 42 042 This is sometimes reported only for IUD and which providers used sterile NORPLANT® insertions, since strict sterility is gloves not fully necessary for the other procedures.

96. Percent of providers observed to V 0 8,9 08 Present as a pie chart. Use q.8 as a filter. take action with FP clients who 09X1 to 09X77 present problems with method

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments v = frequently used indicator numbers

97. Percent of revisit FP clients with F 65 F65 Compare this to the previous indicator. problems who feel they received proper attention from the provider

98. Percent of providers who report 5 23 523X1 to 523X7 Present as a pie chart. that they would properly treat a pill client without her menses at the time of the consultation

99. Percent of FP clients assessed v 0 3,4 03X3 to 03X6 properly for 5TOs 04X8

100. Percent of providers observed to v 0 18,19 018 Present as a bar chart. Use q.18 as a filter. take action with clients 019X1 to 019X77

);­ suspected of having an 5TO :::J ~ 101. Percent of providers reporting 5 26 526X1 to 526X9 Present as a bar chart. Compare this to the iii "0 that they would take action with previous indicator. ~ clients with 5TOs ..... al 102. Percent of providers reporting 5 27 527X1 to 527X8 Present as a bar chart. that they would take action with clients with HIV/AI05

103. Percent of providers reporting 5 28 528 that they test antenatal clients for syphilis

104. Percent of providers who report 5 21,21 a 521 Present as a bar chart by method. that they would not recommend 521AX1 to 521AX77 methods to clients with 5TOs

I = Inventory 0 = Observation guide F = FP exit interview S = Staff interview M = MCH exit interview Quality indicator Instr. Question Variables Comments V" = frequently used indicator numbers

105. Percent of providers who report S 25 S25X1 to S25X98 Present as a bar chart by method. various advice that they would give to a pill client at high risk of STDs

106. Percent of FP clients recieving V" F 3A F3, Present as a bar chart. other services F4X1 to F4X16 These results can also be compared to MCH clients (MCH interview q.3). IMechanisms to encourage continuity I 107. Percent of FP clients who were 0 33,34 033,034 Present as a pie chart with three slices: no observed to receive a written follow-up date, unwritten follow-up date, and follow-up date written follow-up date. >:::J e!. ~. 108. Percent of FP clients reporting V" F 22 F22 To compare this to previous indicator, link the II> 3 12. that they were given a follow-up FP exit interview with the observation. ~ date ..... --.j «) 109. Percent of FP clients who V" 0 28 028 received a supply of their method today

110. Mean cycles of pills supplied to 0 6,23,25, 06,023,025,032 First, determine method used, from q.6,23, FP clients 32 and 25, depending on the type of client. Then give amount supplied, from q.32.

111 . Percent of pill clients reporting F 78 F78 In order to compare this to the observation, that they received a pill supply link the observation and exit files. 3

112. Mean cycles of pills that S 24 S24 This measures the intention of staff to providers report they would resupply, not the actual availability of the provide to successful pill users supplies. at each visit

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments t/ = frequently used indicator numbers

113. Mean pieces of condoms/ 0 6,23,25, 06,023,025,032 First, determine method used, from q.6,23, spermicide supplied to clients 32 and 25, depending on the type of client. Then give amount supplied, from q.32.

114. Among FP clients who did not 0 29 029 Present as a bar chart. receive a supply of their chosen method, reason for lack of supply

115. Among FP clients who did not V- 0 30,31 030,031 Present as a bar chart by method. receive a supply of their chosen method, percent who were given a supply of an alternative method ~ III 116. Percent of FP clients told where t/ 0 35,36 035 Present as exploded pie. ~ iii' to go for resupply 036X1 to 036X5 "0 6l ::l 117. Among pill clients who did not F 79 F79 Present as pie chart.

-" receive supply of pills today, ~ alternate source of supply

118. Among condom/spermicide F 98,99 F98,F99 Present as pie chart. clients who did not receive supply of condoms/ spermicides today, alternate source of supply

119. Among injectable clients who did F 89,90 F89,F90 Present as pie chart. Use q.89 as a filter. not receive injection today, alternate source for injection

120. Percent of MCH clients who go M 47,48 M47,M48 elsewhere for FP services, and reason

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V' = frequently used indicator numbers

Appropriateness and acceptability of services

121. Percent of FP clients generally F 1 F1 Often, this indicator has a very positive result satisfied with their visit because clients want to be polite. This "courtesy bias" reduces the indicator's validity.

These results can also be compared to MCH clients (MCH interview q.2).

122. Percent of FP clients satisfied V' F 5,15,16 F5, F15, F16 These include: the client received the with particular aspects of the information she wanted, had enough privacy, services and understood the provider.

~ These results can also be compared to MCH :J III ~ clients (MCH interview q.4, 14, 15). iii "0 iil 123. Percent of FP clients with other F 31,32, F31,F32,F33 Present especially q.33 as pie chart. :J SOPs nearer to their homes, and 33 ...... reason for coming to this SOP These results can also be compared to MCH ~ instead clients (MCH interview q.32,33, 34).

124. Percent of FP clients who find V' F 23 F23 These results can also be compared to MCH the clinic hours convenient clients (MCH interview q.27).

125. Of those FP clients who find the F 23,24 F23,F24 Present as a pie chart. Use q.23 as a filter hours inconvenient, hours that would be preferable

126. Percent of FP clients who have F 25 F25 These results can also be compared to MCH ever been turned away from this clients (MCH interview q.28). SOP during working hours

I = Inventory 0 = Observation guide F = FP exit interview S = Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V' = frequently used indicator numbers

127. Mean delay between official V' I 1,2,3 11,12,13 Note also how long the first FP client waited. opening time and start of services

128. Mean reported waiting time V' F 26 F26 Note that this data is sometimes inaccurate among FP clients because clients may not have been keeping track of their waiting time.

These results can also be compared to MCH clients (MCH interview q.16).

129. Percent of FP clients satisfied V' F 26,27 F26,F27 Compare this to the reported waiting time, with waiting time above.

~ These results can also be compared to MCH III ~ clients (MCH interview q.16, 17). iii "'C iii' 130. Mean, minimum, and maximum V' Page 52 TIMEBEG This is usually reported separately among ::J a ... duration of FP consultation Page 58 TIMEEND, DUR new and revisit FP clients. Use TIMEBEG and ~ TIMEEND to check DUR . 131. Percent of FP clients satisfied V' F 6 F6 Compare this to the observed consultation with duration of FP consultation time, above. This involves linking the observation with the exit interview.3

These results can also be compared to MCH clients (MCH interview q.5).

132. Mean cost charged for each V- I 38 138A1 to 138A12 These are usually reported by sector. method 138B1 to 138B12 Compare these to the total costs incurred by 133. Mean cost charged for STD/HIV, V- I 38 138A13 to 138A26 clients (indicators 134 and 135). antenatal, postnatal, RH, and 138B13 to 138B26 MCH services

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Quality indicator Instr. Question Variables Comments V = frequently used indicator numbers

134. Mean cost paid by clients for F 34,35, F34,F35,F36 Can report this combined with the next consultation/ medicines / other 36 indicator as total cost to clients. consumables These results can also be compared to MCH clients (MCH interview variables M37X1 to M37X3).

135. Average cost paid by clients for F 37,38, F37,F38,F39 Can report this combined with the previous registration, travel, other 39 indicator as total cost to clients.

These results can also be compared to MCH clients (MCH interview variables M37X4 to M37X6).

~ 136. Percent of FP clients satisfied F 40 F40 Compare this to the cost paid for services. $ll ~ with the cost of services iii These results can also be compared to MCH "0 iii" ;;;) clients (MCH interview q.38).

... 137. Mean travel time required by FP V F 28 F28 These results can also be compared to MCH ~ clients clients (MCH interview q.29).

138. Percent of FP clients taking F 29 F29 Present as a pie chart. various means of travel to the SOP These results can also be compared to MCH clients (MCH interview q.30).

I =Inventory 0 =Observation guide F =FP exit interview S =Staff interview M =MCH exit interview Notes to analysis plan tion of providers who impose these barriers, as well as the extent of those barriers among 1. This analysis is usually performed as those who impose them. follows. First, calculate the FP client load Indicator 61 requires a count of those pro­ among all SDPs, as required by indicator 13. viders who impose each barrier on each Then, sort the SDPs by client load, with the method. How many providers, for example, largest client loads first, progressing to the require a client to be married before they smallest client loads. With the SDPs in this will prescribe an IUD? Each combination of order, divide them into four equal groups, or barrier and method will result in a specific quartiles. If there are 200 SDPs in the study, result, giving 20 pieces of information (4 this will result in four groups of 50 SDPs, the barriers x 5 methods). This information is first group consisting of the 50 largest SDPs, usually presented as a table or bar chart by and the fourth group consisting of the 50 method. smallest SDPs. The percent of providers who impose par­ Each of these four groups serve a certain ity, marital status, and spousal consent barri­ percentage of the overall client load. From ers on each method can be easily calculated the client load information, it is possible to from questions 15, 17, and 18 of the staff in­ sum to a total number of clients served by terview. The percent of providers who im­ the entire FP system. This total can be used pose age barriers is more complicated. In as the denominator to determine the percent questions 11 and 12, staff are asked first of clients served by each quartile of SDPs. whether there is a minimum age below For example, suppose the 200 SDPs men­ which they will not prescribe methods, and tioned above handle 12,000 client visits per if so, are asked to state what that age is. If a year. This averages to 60 clients per SDP per provider says that she has no minimum age year. But some SDPs are quite large, and requirement for pills, for example, then she others quite small. If the largest quartile of clearly does not impose an age barrier. If a SDPs are grouped together, we may find that provider reports that she requires a client to as a group, they serve 8,000 clients, or 75% be 21 before providing pills, then she clearly of the total annual client load. The remain­ does impose an age barrier. ing three quartiles may serve 12%,8%, and But some providers might say they re­ 5% of the total client load, respectively. quire a client to be only 10 or 12 years old These very skewed findings are quite typi­ for the pill. By many program standards, this cal, and may point to differences in quality is effectively not an age barrier. Similarly, between the high load and low load SDPs. providers might say that their maximum age limit for condom distribution is 75. Clearly 2. The indicators on barriers to services this is an age barrier in name only, and does are concerned with four barriers (age, mari­ not pose a significant barrier for clients. In tal status, parity, and spousal consent), and these cases, providers who say they have five methods (COC, condom, IUD, minimum or maximum age barriers but injectables, and sterilization). The idea of in­ whose actual thresholds are extremely low dicators 61 and 62 is to measure the propor- or high, should not be considered to be im-

Notes to analysis plan • 184 posing age barriers. The analyst must agree This is achieved through the identifying with program managers on the minimum variables on the first page of each question­ and maximum age that will be considered naire. For example, indicator 76 is "Percent true barriers for each method. Then, provid­ of FP clients with whom IEC materials were ers whose age constraints fall outside these used (at SDPs with IEC materials available)." thresholds will not be considered to be im­ This requires a link between the inventory­ posing age barriers. The data from questions to know if IEC materials were present-and 11 through 14 must be very carefully ana­ the observation-to know if the materials lyzed with these issues in mind. were actually used during the consultation. Indicator 62 concerns itself with the na­ Both the inventory and the observation have ture of the age and parity barriers that are the variable HFCODE, which should identify imposed. In other words, among those pro­ the health facility across both modules. In viders who do impose a minimum age limit the observation, the HFCODE variable is the for pills, what is the mean age required? link back to the inventory, which supplies These means should be calculated only the information on IEC availability. Similarly, among those providers that do impose a both the observation and the exit interview true age barrier. Remember that providers share a variable CLIID, which should be the whose age barriers are outside the thresh­ same for all clients. This variable should link olds established for indicator 61 should not the observation and exit interview directly. be included in these means. As for parity, re­ These linking variables must identify cases quiring even one child for any method (in­ uniquely. That is, the variable HFCODE must cluding IUD) is usually considered a barrier, have a different value for each SDP-no two so this mean should be calculated among all SDPs can share the same health facility those providers who declare in question 15 code. Likewise, no two staff members at the that they impose any parity reqUirement same SDP should have the same STAFFID. whatsoever. In this way, the combination of HFCODE and STAFFID identifies providers uniquely. 3. Linking data between modules requires Also, no two clients who were observed patience, but it allows for a much richer and with the same provider should have the more informative analysis. In several indica­ same CLIID. The combination of HFCODE, tors, links are required between the inventory STAFFID, and CLIID should identify each cli­ and the observation; the inventory and the FP ent uniquely. If these variables do not iden­ exit interview; and the observation and the FP tify cases uniquely, you will not be able to exit interview. In other words, it is sometimes link across modules. For this reason, check necessary to know not only at which SDP a and clean these variables thoroughly before particular observation took place, but also linking. have access to inventory information about In Epi Info, a variable that is shared be­ that SDP. Likewise, it is sometimes necessary tween two datasets can link two ftles with the to have information from the observation of command RELATE. In SPSS, the shared vari­ a particular client to compare to her re­ ables can link two datasets with the MATCH sponses on the exit interview. FILES command with a TABLES subcommand.

Notes to analysis plan • 185 See the relevant manuals for more information considered in this way and scored appropri­ on how to use these commands. ately, given the program's objectives and ex­ pectations. 4. Knowledge scores can be calculated in Once each question is scored in this way, a variety of ways. In general, the objective is each client will result with a score from 0 to to produce a score for each client that is 6. This is useful for pill clients, but it would easily interpreted, and that gives an idea of be useful to be able to compare pill clients' the amount of knowledge she has about a knowledge with the knowledge of users of particular topic. One method of calculation other methods. But if there are, for example, that has been used in SA studies is to simply 4 questions on injectables, then the scales calculate the percentage of questions that are different and the results are not compa­ the client responds to appropriately. rable. For this reason, knowledge scores are For example, there are six pill knowledge usually normalized to a percentage. The pill questions in the exit interview (questions 72 client who answers 3 of 6 questions cor­ through 77). In the simplest model, the cli­ rectly is given a score of .50. The injectable ent would be given a score of 0 to 6, to indi­ client who answers 3 of 4 questions cor­ cate the number of questions she answered rectly is given a score of .75. These results correctly. However, not all questions have are comparable. such a clearly "correct" answer. Question 76, Previous versions of the staff interview for example, requires that a client list the also included knowledge questions by side effects of the pill that she is aware of. method. This allowed for calculation of staff The table includes six side effects, but the knowledge scores, which were a useful indi­ client should certainly not be required to cator of technical competence. Unfortu­ mention all six. The analyst must first decide nately, the extremely long series of what threshold to use-for example, the cli­ questions led to protests from the ent might be required to mention any two or interviewees, so these questions were dis­ three side effects in order to be seen as continued. However, some knowledge ques­ "knowledgeable" on side effects. In this way, tions still remain, such as the methods if she mentions enough side effects, she is recommended for spacing and limiting considered to have answered the side effects births, which could also form the basis of question "correctly." Each question must be knowledge scores.

Notes to analysis plan • 186 Sample indicator lists

As mentioned earlier, no SA report would For reference, two such lists are included in include all 138 indicators listed in the analy­ Tables 2 and 3, from Senegal and Botswana. sis plan because that is simply too much in­ These are the aetuallists that were used for pri­ formation to process effectively. Similarly, mary or secondary analysis ofSA data, and are many studies manipulate the data in differ­ being used by program managers to evaluate ent ways and devise their own indicators their programs and design interventions. The that are not listed above. The result is that Senegal list presents a fairly standard collec­ each country's list of indicators is unique, a tion of indicators. In Botswana, many new in­ product of consensus among program man­ dicators on reproductive health were added, agers and researchers. and the Situation Analysis instruments were altered significantly to collect the relevant information.

Sample indicator lists • 187 TABLE 2. Senegal indicators, 1994 Functional capacity indicators Training 1. Percent of staff trained in clinical family planning 2. Percent of staff trained in family planning counseling Services offered 3. Percent of SDPs that offer the minimum package of MCH/FP services on demand Equipment and supplies 4. Percent of SDPs with all equipment necessary for family planning services 5. Percent of SDPs with 70% of the equipment necessary for family planning services 6. Percent of SDPs with 50% of equipment necessary for IUD insertion/removal Commodities and logistics 7. Percent of SDPs with a written inventory of received stock 8. Percent of SDPs having a stock-out of anyone method in the last six months 9. Percent of SDPs having a stock-out of COC in the last six months 10. Percent of SDPs having a stock-out of injectables in the last six months Supervision and management 11. Percent of SDPs that received a supervisory visit in the three months prior to the study 12. Percent of family planning registers properly filled in 13. Percent of SDPs that have sent a report during the last month Quality of care indicators 1. Percent of family planning clients able to furnish half the requested information about their method: total 2. ... among pill users 3. ... among IUD users 4. ... among injectable users 5.... among NORPLANT® users 6. Percent of new clients who did not receive the method of their choice (for nonmedical reasons) 7. Percent of family planning clients with whom at least one other service was discussed 8. Percent of MCH clients who heard about family planning services from a provider 9. Percent of providers who follow the norms and protocols of MCH/FP service delivery: Understanding client needs a. Provider asks clients about reproductive intentions b. Provider asks clients if breastfeeding c. Provider asks new clients if they have concerns about any method d. Provider asks revisit clients if they want to stop or change methods e. Provider asks revisit clients if they had problems with their method f. Provider addresses problems expressed by revisit clients g. Provider discusses STDs with clients h. Average of understanding client needs Choice of method a. Provider mentions at least one method other than that accepted b. Provider describes at least one method other than that accepted c. Provider does not overtly encourage one method in particular d. Provider imposes barriers on half or fewer of the methods offered at the SDP e. Provider recommends the appropriate methods for spacing and limiting in most cases f. Provider ascertains clients' method preference g. Provider refers clients if method unavailable h. Average of choice of method

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Sample indicator lists • 188 Senegal indicators, 1994, continued Quality indicator 9, continued: Information given to clients a. Provider informs new acceptors how to use method b. Provider informs new acceptors of advantages of method c. Provider informs new acceptors of disadvantages of method d. Provider informs new acceptors of side effects of method e. Provider informs new acceptors of the possibility of changing methods f. Provider informs new clients that condoms prevent STDs/HIV g. Provider uses lEG materials h. Provider uses contraceptive sample i. Average of information given to clients Technical competence a. Provider takes medical history b. Provider asks clients for LMP c. Provider asks clients about unusual bleeding d. Provider asks clients about STD symptoms e. Provider takes clients' BP f. Provider weighs clients g. Provider performs physical exam h. Provider performs pelvic exam i. Provider follows all protocols for pelvic exam j. Provider follows all protocols for IUD insertion k. Provider follows all protocols for injections I. Provider follows all protocols for NORPLANT@ insertion m. Average of technical competence Mechanisms for ensuring continuity a. Provider tells clients when to return b. Provider gives clients written or nonverbal reminder of return c. Provider tells clients where to go for resupply d. Provider informs new acceptors what to do if have problems e. Average of mechanisms for ensuring continuity Interpersonal relations a. Provider greets clients in a friendly manner b. Provider was easily understood by clients c. Provider gives enough time for consultation d. Provider answers clients' questions satisfactorily e. Provider's clients feel waiting time was reasonable f. Provider's clients feel consultation was sufficiently private g. Average of interpersonal relations

Sample indicator lists • 189 TABLE 3. Botswana indicators, 1995 Functional capacity indicators Training 1. Percentage of staff trained in counselling, STD/HIV management, MGH/FP, and lEG, by type of training (pre-service, in-service, post-basic) 2. Mean years since each type of training Integration 3. Percentage of health facilities that offer MGH/FP and STD/HIV services on a daily basis 4. Percentage of health providers carrying out STD risk assessment in MGH/FP clients 5. Percentage of health providers carrying out STD counselling in MGH/FP clients 6. Percentage of health providers promoting dual methods 7. Percentage of health providers who ask or counsel STD clients about FP use 8. Percentage of clients receiving services other than the one sought for Orientation of new officers 9. Percentage of health facilities that have a current standard orientation package 10. Percentage of new officers that have been oriented and have the standard orientation package Research and evaluation 11. Percentage of planned research projects in RH that have been carried out 12. Percentage of projects in RH that have been evaluated according to plan 13. Percentage of completed research studies that have been disseminated Equipment and supplies 14. Percentage of facilities with functioning standardized basic equipment 15. Percentage of facilities with adequate (3 month buffer) supply of unexpired stock Information, education, communication 16. Percentage of health facilities with poster/flip chart/pamphlet on MGH, STD/AIDS, or FP 17. Percentage of clients given any lEG material on RH Infrastructure 18. Percentage of facilities with working clients' toilets 19. Percentage of facilities with functioning water source on the compound 20. Percentage of facilities with sheltered waiting areas 21. Percentage of facilities with separate counselling/exam room 22. Percentage of facilities with working source of energy Infection control 23. Percentage of facilities with equipment for keeping/holding/decontaminating used medical equip­ ment/supplies (sharps container, dustbin) 24. Percentage of facilities with adequate medical waste disposal mechanisms (pits, burning, incinera­ tion) Accessibility 25. Percentage of facilities that are observed to give RH services after 1:45 pm 26. Percentage of clients indicating that waiting time is acceptable 27. Mean waiting time 28. Percentage of facilities with signs to facilitate client flow Supervision 29. Percentage of planned visits that have been honored 30. Percentage of supervised health facilities that received feedback Management 31. Percentage of DHTs with up-to-date guidelines, service standards, and reference manuals 32. Number of filled posts compared to established posts 33. Percentage of health facilities that have experienced a stock-out in last 3 months 34. Percentage of facilities with well-completed data collection tools (tally sheets, stock books, monthly summary forms, registers, FWE record books) Transport and communication 35. Percentage of facilities/institutions with a vehicle in working condition 36. Percentage of facilities/institutions with a mode of communication

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Sample indicator lists • 190 Botswana indicators, 1995, continued Quality of services Policy 37. Percentage of facilities with current policy documents Information given to clients 38. Percentage of new clients given information on all appropriate methods available 39. Percentage of new clients given information on accepted method Choice of methods 40. Percentage of clients referred if method unavailable 41. Percentage of providers who report that they impose restrictions on methods due to age, parity, marital status, or spousal consent Interpersonal relations 42. Percentage of clients who received a welcome by being greeted and offered a chair 43. Percentage of clients who feel they were provided with privacy 44. Percentage of clients allowed to ask questions 45. Percentage of clients satisfied with time spent with provider Mechanisms to encourage continuity 46. Percentage of clients who were informed of when to return for resupply/checkup 47. Percentage of clients past due dates who have been contacted through follow-up Technical competence 48. Percentage of new clients who underwent: blood pressure weight physical exam breast exam pelvic exam STD screening urinalysis medical history 49. Percentage of providers who can demonstrate skills in clinical procedures according to stipulated guidelines and service standards: Taking weight Physical exam Breast exam Urinalysis History taking IUD insertion Pap smear collection STD management using syndromic approach STD risk assessment Injection 50. Percentage of providers demonstrating skills in use of visual aids during counselling (e.g. models, flip charts, booklets, posters) Impact 51. Percentage of clients knowledgeable on prevention of STD/HIV/AIDS 52. Percentage of clients knowledgeable on signs/symptoms of STD/HIV/AIDS 53. Percentage of clients using other methods of FP who accepted condom during that visit 54. Percentage of clients who were using dual methods and still continue using

Sample indicator lists • 191 Sample graphs

Once the indicators have been selected and and more easily interpreted than tables with calculated, they should be presented in the numbers. final report as effectively as possible. Usu­ The following twelve charts give ex­ ally, the results are presented as bar or pie amples of some of the most common SA charts, as appropriate, and a typical report findings and how they can be effectively might contain as many as sixty such charts. presented in charts. The data are from a re­ This type of presentation is generally clear cent study conducted in Africa.

Sample graphs • 192 Percent of SDPs that usually offer FP methods Percent of SOPs missing selected equipment

Sterilizer

Exam lamp 59

D.• BP machIne Q tn '0 ~ 3+ Specula :. 3+ Gloves

EPI refrlg. ! o 20 40 60 80 100 (J) COC POP Condom IUD Depo Provera Percent of SDPs I n=186 n=186 CD l,Q i Indicator 11 Indicator 24 UI .....• ~ Percent of staff whose training included various issues Percent of SDPs with lEe materials on various sUbjects

100 I------~~--- I .Posters I Child welfarell!JJW)J8Jd&ffJ.JJJJ 67] 9f • 80 ~n------. WlJ'JI!lI-P_bJ~t' Family planning ""••91 ~ II 66.... • Flip chart Ul 60 I11III60 STD management '0.. Antenatal care 66 i :.e Postnatal care

o !O e IIII~aSIC ~qf ,.;:.Q ~~OJ ,..r­ ~~Q" (itl ~ p~.t.ba.lc ~,.~~ (i HIV/AIDS mgt. 5~ i ,: .J. .:I' ~~ ~~ ~ ~~ ~ ~~~ ~,§:'~ o 20 40 60 80 100 CJ~ ~~ qo'ii ~~ Percent of staff " n=451 n=186 Indicators 27 and 31 Indicator 36 Percent of SOPs experiencing stockouts Percent of new FP clients who were told of contraceptives in the previous six months about various methods

100 - Pill unspecifiediiii 1 COC pOP _;_ r' l==-~-==~==----- Condoms 49 5:: IUD ~6 '0 .. Injectable 3~ lii 40 ~------j l:! Dual methods 1 :. 23 Spermlcldes i Female stern. .. i

NORPLANl"'''"'- ~__~__~__~____! o 20 40 60 80 100 &' COC POP Condom IUD Depo Provera Percent of new FP clients 3 "0 n=186 n=74 CD co ~ Indicator 39 Indicator 56 rn .....• ~ Percent of providers who impose barriers Percent of new FP clients who received information on various methods on their accepted method

100 'I------How to use i I

80;I 78------l6------j1 r! Side effects ~ ! _ 66 _70. ~ "> _ _63 1 2 60 Mgt. of problems CI. '0 Advantages C 40 --- Disadvantages J 20 --- Possible to switch o Pili Condom IUD Injectable Relationship with SlDs ~ o 20 40 60 80 100 ~ • Mlmlnum age No. of children Percent of new FP clients

n=456 n=66 Indicator 61 Indicator 73 Percent of FP clients with whom Percent of FP clients who are other health services were discussed knowledgeable about STDs/HIV symptoms

Genital lesions BreaStfeedlng. _ "~7I !i iI 49 i Weight loss srDs 26 Vaginal discharge Diarrhea HIV/AIDS Painful urination iIIIINo.ononto Genital Itching ~ Rovlllt cllonto Immunization Genital warts Lower abdominal pain Child health Urethral discharge Painful Intercourse Infertility Abnormal bleedlng"'----2_~____'___.~_~______' o 20 40 60 80 100 o 20 40 60 80 100 en Percent of FP clients Percent of FP clients ~ 12­ New n = 74 Revisit n = 326 n=385 lD co ~ Indicator 75 Indicator 83 (Jl o -"co 01 Percent of pelvic exams Percent of providers who would give advice during which providers performed various actions to a pill client at risk of STDs

Inform beforehand Use pill and condom

Wash hands before Stop pili, use condom Use sterile speculum

Use sterile gloves Stop all methods Inform afterwards Other advice Wash hands afterwards /II! ! Take Pap smearI 4 Don't knowI3 ""'----_--"---_---L_-----"~_...i_.__ "'------'--~-----'----- o 20 40 60 80 100 o 20 40 60 80 100 Percent of pelvic exams Percent of providers

n=54 n=451 Indicator 91 Indicator 105